Microwave-induced combustion for petroleum coke digestion: a promising sample preparation strategy for subsequent elemental determination

The increasing demand for the elemental determination of petrochemical samples by inductively coupled plasma techniques requires the development of suitable sample preparation methods that permit high sample throughput and are in accordance with green chemistry recommendations. For this aim, the development of microwave-induced combustion (MIC) method has been attempted to completely digest petroleum coke samples and address quantitative determination of elements, such as Ag, Al, Ba, Ca, Cd, Co, Cu, Fe, Mg, Mn, Mo, Na, Ni, Pb, Sr, V and Zn, by inductively coupled plasma optical emission spectrometry (ICP OES). A sequential procedure to evaluate the sample mass and the solution to retain the analytes quantitatively was first conducted. Satisfactory results were obtained (residual carbon content in final solutions was lower than 0.5%) by digesting 400 mg of samples using 20 bar of oxygen and analytes were quantitatively retained in a dilute acid solution such as 4.2 mol L^-1 HNO₃. An agreement better than 87% was achieved using certified reference materials and the performance of the proposed method was also compared to that of the standard procedure recommended by the American Society of Testing and Materials ASTM D 5600. Despite both methods producing similar results, the proposed method by MIC was much simpler, offered a higher sample throughput and the digests were compatible with ICP OES measurements avoiding interferences in the determination step compared the ASTM D 5600 method. These results clearly demonstrated that the proposed MIC method in combination with ICP OES could be a promising alternative to obtain quantitative information about the elemental composition of petroleum coke.

What is an appropriate caesarean delivery rate for China: a multicentre survey

Objective

To assess the current status of caesarean delivery (CD) in China, propose reference CD rates for China overall, and by regions, investigate the main indications for CDs and identify possible areas for safe reduction.

Design

A multicentre cross‐sectional study.

Setting

A total of 94 hospitals across 23 provinces in China.

Population

A total of 73 977 randomly selected deliveries.

Methods

We used a modified Robson classification to characterise CDs in subgroups and by regions, and the World Health Organization (WHO) C‐Model to calculate reference CD rates.

Main outcome measures

CD rates in China.

Results

In 2015–2016, the overall CD rate in China was 38.9% (95% CI 38.6–39.3%). Considering the obstetric characteristics of the population, the multivariable model‐based reference CD rate was estimated at 28.5% (95% CI 28.3–28.8%). Accordingly, an absolute reduction of 10.4% (or 26.7% relative reduction) may be considered. The CD rate varied substantially by region. Previous CD was the most common indication in all regions, accounting for 38.2% of all CDs, followed by maternal request (9.8%), labour dystocia (8.3%), fetal distress (7.7%) and malpresentation (7.6%). Overall, 12.7% of women had prelabour CDs, contributing to 32.8% of the total CDs.

Conclusions

Nearly 39% of births were delivered by caesarean in China but a reduction of this rate by a quarter may be considered attainable. Repeat CD contributed more than one‐third of the total CDs. Given the large variation in maternal characteristics, region‐specific or even hospital‐specific reference CD rates are needed for precision management of CD.

Tweetable abstract

The caesarean rate in 2015–2016 in China was 38.9%, whereas the reference rate was 28.5%.

The caesarean rate in 2015–2016 in China was 38.9%, whereas the reference rate was 28.5%.

Linked article This article is commented on by M Varner, p. 148 in this issue. To view this mini commentary visit https://doi.org/10.1111/1471-0528.16953.

Development of the FAST-M maternal sepsis bundle for use in low-resource settings: a modified Delphi process

Objective

To develop a sepsis care bundle for the initial management of maternal sepsis in low resource settings.

Design

Modified Delphi process.

Setting

Participants from 34 countries.

Population

Healthcare practitioners working in low resource settings (n = 143; 34 countries), members of an expert panel (n = 11) and consultation with the World Health Organization Global Maternal and Neonatal Sepsis Initiative technical working group.

Methods

We reviewed the literature to identify all potential interventions and practices around the initial management of sepsis that could be bundled together. A modified Delphi process, using an online questionnaire and in‐person meetings, was then undertaken to gain consensus on bundle items. Participants ranked potential bundle items in terms of perceived importance and feasibility, considering their use in both hospitals and health centres. Findings from the healthcare practitioners were then triangulated with those of the experts.

Main outcome measure

Consensus on bundle items.

Results

Consensus was reached after three consultation rounds, with the same items deemed most important and feasible by both the healthcare practitioners and expert panel. Final bundle items selected were: (1) Fluids, (2) Antibiotics, (3) Source identification and control, (4) Transfer (to appropriate higher‐level care) and (5) Monitoring (of both mother and neonate as appropriate). The bundle was given the acronym ‘FAST‐M’.

Conclusion

A clinically relevant maternal sepsis bundle for low resource settings has been developed by international consensus.

Tweetable abstract

A maternal sepsis bundle for low resource settings has been developed by international consensus.

A maternal sepsis bundle for low resource settings has been developed by international consensus.

Diagnostic accuracy of the partograph alert and action lines to predict adverse birth outcomes: a systematic review

BACKGROUND

There are questions about the use of the 'one-centimetre per hour rule' as a valid benchmark for assessing the adequacy of labour progress.

OBJECTIVES

To determine the accuracy of the alert (1-cm/hour) and action lines of the cervicograph in the partograph to predict adverse birth outcomes among women in first stage of labour.

SEARCH STRATEGY

PubMed, EMBASE, CINAHL, POPLINE, Global Health Library, and reference lists of eligible studies.

SELECTION CRITERIA

Observational studies and other study designs reporting data on the correlation between the alert line status of women in labour and the occurrence of adverse birth outcomes.

DATA COLLECTION AND ANALYSIS

Two reviewers at a time independently identified eligible studies and independently abstracted data including population characteristics and maternal and perinatal outcomes.

MAIN RESULTS

Thirteen studies in which 20 471 women participated were included in the review. The percentage of women crossing the alert line varied from 8 to 76% for all maternal or perinatal outcomes. No study showed a robust diagnostic test accuracy profile for any of the selected outcomes.

CONCLUSIONS

This systematic review does not support the use of the cervical dilatation over time (at a threshold of 1 cm/h during active first stage) to identify women at risk of adverse birth outcomes.

TWEETABLE ABSTRACT

Alert line of partograph does not identify women at risk of adverse birth outcomes.

EQUIPAMENTO MÓVEL DE AUXÍLIO A COLHEITA DE BATATA (Solanum tuberosum L.)

A produção de batatas foi introduzida no Brasil primeiramente pelo Sul do país onde as condições climáticas eram mais favoráveis para sua produção. A partir do início do século 21, a produção se expandiu para São Paulo e Minas Gerais. A batata é um tubérculo comestível, rico em amido e carboidratos, sendo relevante para a economia brasileira e sua produtividade no país está crescendo. Este trabalho teve como objetivo apresentar uma solução para os pequenos produtores que desejam investir em melhorar as condições de recolhimento de batata, tendo como principal foco o aumento de eficiência de 13,3% do que o produtor gasta hoje com mão de obra e aumento de produtividade do trabalho na lavoura de 33% em relação ao tempo atual, além da melhoria da saúde e redução da penosidade do trabalhador de campo. Para o desenvolvimento do protótipo foram levantados dados de campo de cultura do tubérculo. A carga no protótipo foi testada usando simulação de tensões aplicadas nos componentes. Esta máquina tem mecanismos que facilitam o processo de recolhimento de batatas no campo. A implementação do equipamento visou diminuir o risco ergométrico postural dos trabalhadores desta atividade.

Postpartum hemorrhage: new insights for definition and diagnosis

The current definition of is inadequate for early recognition of this important cause of maternal death that is responsible for >80,000 deaths worldwide in 2015. A stronger definition of postpartum hemorrhage should include both blood loss and clinical signs of cardiovascular changes after delivery, which would help providers to identify postpartum hemorrhage more promptly and accurately. Along with the amount of blood loss, clinical signs, and specifically the shock index (heart rate divided by systolic blood pressure) appear to aid in more accurate diagnosis of postpartum hemorrhage.

Cervical dilatation over time is a poor predictor of severe adverse birth outcomes: a diagnostic accuracy study

OBJECTIVE

To assess the accuracy of the World Health Organization (WHO) partograph alert line and other candidate predictors in the identification of women at risk of developing severe adverse birth outcomes.

DESIGN

A facility-based, multicentre, prospective cohort study.

SETTING

Thirteen maternity hospitals located in Nigeria and Uganda.

POPULATION

A total of 9995 women with spontaneous onset of labour presenting at cervical dilatation of ≤6 cm or undergoing induction of labour.

METHODS

Research assistants collected data on sociodemographic, anthropometric, obstetric, and medical characteristics of study participants at hospital admission, multiple assessments during labour, and interventions during labour and childbirth. The alert line and action line, intrapartum monitoring parameters, and customised labour curves were assessed using sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio, and the J statistic.

OUTCOMES

Severe adverse birth outcomes.

RESULTS

The rate of severe adverse birth outcomes was 2.2% (223 women with severe adverse birth outcomes), the rate of augmentation of labour was 35.1% (3506 women), and the caesarean section rate was 13.2% (1323 women). Forty-nine percent of women in labour crossed the alert line (4163/8489). All reference labour curves had a diagnostic odds ratio ranging from 1.29 to 1.60. The J statistic was less than 10% for all reference curves.

CONCLUSIONS

Our findings suggest that labour is an extremely variable phenomenon, and the assessment of cervical dilatation over time is a poor predictor of severe adverse birth outcomes. The validity of a partograph alert line based on the 'one-centimetre per hour' rule should be re-evaluated.

FUNDING

Bill & Melinda Gates Foundation, United States Agency for International Development (USAID), UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), and WHO (A65879).

TWEETABLE ABSTRACT

The alert line in check: results from a WHO study.

Cervical dilatation patterns of 'low-risk' women with spontaneous labour and normal perinatal outcomes: a systematic review

BACKGROUND

The call for women-centred approaches to reduce labour interventions, particularly primary caesarean section, has renewed an interest in gaining a better understanding of natural labour progression.

OBJECTIVE

To synthesise available data on the cervical dilatation patterns during spontaneous labour of 'low-risk' women with normal perinatal outcomes.

SEARCH STRATEGY

PubMed, EMBASE, CINAHL, POPLINE, Global Health Library, and reference lists of eligible studies.

SELECTION CRITERIA

Observational studies and other study designs.

DATA COLLECTION AND ANALYSIS

Two authors extracted data on: maternal characteristics; labour interventions; the duration of labour centimetre by centimetre; and the duration of labour from dilatation at admission through to 10 cm. We pooled data across studies using weighted medians and employed the Bootstrap-t method to generate the corresponding confidence bounds.

MAIN RESULTS

Seven observational studies describing labour patterns for 99 971 women met our inclusion criteria. The median time to advance by 1 cm in nulliparous women was longer than 1 hour until a dilatation of 5 cm was reached, with markedly rapid progress after 6 cm. Similar labour progression patterns were observed in parous women. The 95th percentiles for both parity groups suggest that it was not uncommon for some women to reach 10 cm, despite dilatation rates that were much slower than the 1-cm/hour threshold for most part of their first stage of labours.

CONCLUSION

An expectation of a minimum cervical dilatation threshold of 1 cm/hour throughout the first stage of labour is unrealistic for most healthy nulliparous and parous women. Our findings call into question the universal application of clinical standards that are conceptually based on an expectation of linear labour progress in all women.

FUNDING

UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, and the United States Agency for International Development (USAID).

TWEETABLE ABSTRACT

Cervical dilatation threshold of 1 cm/hour throughout labour is unrealistic for most women, regardless of parity.

Respectful care during childbirth in health facilities globally: a qualitative evidence synthesis

Background

What constitutes respectful maternity care (RMC) operationally in research and programme implementation is often variable.

Objectives

To develop a conceptualisation of RMC.

Search strategy

Key databases, including PubMed, CINAHL, EMBASE, Global Health Library, grey literature, and reference lists of relevant studies.

Selection criteria

Primary qualitative studies focusing on care occurring during labour, childbirth, and/or immediately postpartum in health facilities, without any restrictions on locations or publication date.

Data collection and analysis

A combined inductive and deductive approach was used to synthesise the data; the GRADE CERQual approach was used to assess the level of confidence in review findings.

Main results

Sixty‐seven studies from 32 countries met our inclusion criteria. Twelve domains of RMC were synthesised: being free from harm and mistreatment; maintaining privacy and confidentiality; preserving women's dignity; prospective provision of information and seeking of informed consent; ensuring continuous access to family and community support; enhancing quality of physical environment and resources; providing equitable maternity care; engaging with effective communication; respecting women's choices that strengthen their capabilities to give birth; availability of competent and motivated human resources; provision of efficient and effective care; and continuity of care. Globally, women's perspectives of what constitutes RMC are quite consistent.

Conclusions

This review presents an evidence‐based typology of RMC in health facilities globally, and demonstrates that the concept is broader than a reduction of disrespectful care or mistreatment of women during childbirth. Innovative approaches should be developed and tested to integrate RMC as a routine component of quality maternal and newborn care programmes.

Tweetable abstract

Understanding respectful maternity care – synthesis of evidence from 67 qualitative studies.

Understanding respectful maternity care – synthesis of evidence from 67 qualitative studies.

Development of new materials from waste electrical and electronic equipment: Characterization and catalytic application

Wastes of electrical and electronic equipment (WEEE) represent an important environmental problem, since its composition includes heavy metals and organic compounds used as flame-retardants. Thermal treatments have been considered efficient processes on removal of these compounds, producing carbonaceous structures, which, together with the ceramic components of the WEEE (i.e. silica and alumina), works as support material for the metals. This mixture, associated with the metals present in WEEE, represents promising systems with potential for catalytic application. In this work, WEEE was thermally modified to generate materials that were extensively characterized. Raman spectrum for WEEE after thermal treatment showed two carbon associated bands. SEM images showed a metal nanoparticles distribution over a polymeric and ceramic support. After characterization, WEEE materials were applied in ethanol steam reforming reaction. The system obtained at higher temperature (800°C) exhibited the best activity, since it leads to high conversions (85%), hydrogen yield (30%) and H₂/CO ratio (3,6) at 750°C.

Impact of stillbirths on international comparisons of preterm birth rates: a secondary analysis of the WHO multi-country survey of Maternal and Newborn Health

Objective

To evaluate the extent to which stillbirths affect international comparisons of preterm birth rates in low‐ and middle‐income countries.

Design

Secondary analysis of a multi‐country cross‐sectional study.

Setting

29 countries participating in the World Health Organization Multicountry Survey on Maternal and Newborn Health.

Population

258 215 singleton deliveries in 286 hospitals.

Methods

We describe how inclusion or exclusion of stillbirth affect rates of preterm births in 29 countries.

Main outcome measures

Preterm delivery.

Results

In all countries, preterm birth rates were substantially lower when based on live births only, than when based on total births. However, the increase in preterm birth rates with inclusion of stillbirths was substantially higher in low Human Development Index (HDI) countries [median 18.2%, interquartile range (17.2–34.6%)] compared with medium (4.3%, 3.0–6.7%), and high‐HDI countries (4.8%, 4.4–5.5%).

Conclusion

Inclusion of stillbirths leads to higher estimates of preterm birth rate in all countries, with a disproportionately large effect in low‐HDI countries. Preterm birth rates based on live births alone do not accurately reflect international disparities in perinatal health; thus improved registration and reporting of stillbirths are necessary.

Tweetable abstract

Inclusion of stillbirths increases preterm birth rates estimates, especially in low‐HDI countries.

Inclusion of stillbirths increases preterm birth rates estimates, especially in low‐HDI countries.

Severe maternal morbidity due to respiratory disease and impact of 2009 H1N1 influenza A pandemic in Brazil: results from a national multicenter cross-sectional study

BACKGROUND

The aim of this study was to assess the burden of respiratory disease, considering the influenza A pandemic season (H1N1pdm09), within the Brazilian Network for Surveillance of Severe Maternal Morbidity, and factors associated with worse maternal outcome.

METHODS

A multicenter cross-sectional study, involving 27 referral maternity hospitals in five Brazilian regions. Cases were identified in a prospective surveillance by using the WHO standardized criteria for potentially life-threatening conditions (PLTC) and maternal near miss (MNM). Women with severe complications from respiratory disease identified as suspected or confirmed cases of H1N1 influenza or respiratory failure were compared to those with other causes of severe morbidity. A review of suspected H1N1 influenza cases classified women as non-tested, tested positive and tested negative, comparing their outcomes. Factors associated with severe maternal outcome (SMO = MNM + MD) were assessed in both groups, in comparison to PLTC, using PR and 95 % CI adjusted for design effect of cluster sampling.

RESULTS

Among 9555 cases of severe maternal morbidity, 485 (5 %) had respiratory disease. Respiratory disease occurred in one-quarter of MNM cases and two-thirds of MD. H1N1 virus was suspected in 206 cases with respiratory illness. Around 60 % of these women were tested, yielding 49 confirmed cases. Confirmed H1N1 influenza cases had worse adverse outcomes (MNM:MD ratio < 1 (0.9:1), compared to 12:1 in cases due to other causes), and a mortality index > 50 %, in comparison to 7.4 % in other causes of severe maternal morbidity. Delay in medical care was associated with SMO in all cases considered, with a two-fold increased risk among respiratory disease patients. Perinatal outcome was worse in cases complicated by respiratory disease, with increased prematurity, stillbirth, low birth weight and Apgar score < 7.

CONCLUSIONS

Respiratory disease, especially considering the influenza season, is a very severe cause of maternal near miss and death. Increased awareness about this condition, preventive vaccination during pregnancy, early diagnosis and treatment are required to improve maternal health.

The role of infection and sepsis in the Brazilian Network for Surveillance of Severe Maternal Morbidity

OBJECTIVE

To identify the burden of severe infection within the Brazilian Network for Surveillance of Severe Maternal Morbidity and factors associated with worse maternal outcomes.

METHODS

This was a multicentre cross-sectional study involving 27 referral maternity hospitals in Brazil. WHO's standardised criteria for potentially life-threatening conditions and maternal near miss were used to identify cases through prospective surveillance and the main cause of morbidity was identified as infection or other causes (hypertension, haemorrhage or clinical/surgical). Complications due to infection were compared to complications due to the remaining causes of morbidity. Factors associated with a severe maternal outcome were assessed for the cases of infection.

RESULTS

A total of 502 (5.3%) cases of maternal morbidity were associated with severe infection vs. 9053 cases (94.7%) with other causes. Considering increased severity of cases, infection was responsible for one-fourth of all maternal near miss (23.6%) and nearly half (46.4%) of maternal deaths, with a maternal near miss to maternal death ratio three times (2.8:1) that of cases without infection (7.8:1) and a high mortality index (26.3%). Within cases of infection, substandard care was present in over one half of the severe maternal outcome cases. Factors independently associated with worse maternal outcomes were HIV/AIDS, hysterectomy, prolonged hospitalisation, intensive care admission and delays in medical care.

CONCLUSIONS

Infection is an alarming cause of maternal morbidity and mortality and timely diagnosis and adequate management are key to improving outcomes during pregnancy. Delays should be addressed, risk factors identified, and specific protocols of surveillance and care developed for use during pregnancy.

Clinical pharmacokinetic properties of magnesium sulphate in women with pre-eclampsia and eclampsia

BACKGROUND

The pharmacokinetic basis of magnesium sulphate (MgSO4 ) dosing regimens for eclampsia prophylaxis and treatment is not clearly established.

OBJECTIVES

To review available data on clinical pharmacokinetic properties of MgSO4 when used for women with pre-eclampsia and/or eclampsia.

SEARCH STRATEGY

MEDLINE, EMBASE, CINAHL, POPLINE, Global Health Library and reference lists of eligible studies.

SELECTION CRITERIA

All study types investigating pharmacokinetic properties of MgSO4 in women with pre-eclampsia and/or eclampsia.

DATA COLLECTION AND ANALYSIS

Two authors extracted data on basic pharmacokinetic parameters reflecting the different aspects of absorption, bioavailability, distribution and excretion of MgSO4 according to identified dosing regimens.

MAIN RESULTS

Twenty-eight studies investigating pharmacokinetic properties of 17 MgSO4 regimens met our inclusion criteria. Most women (91.5%) in the studies had pre-eclampsia. Baseline serum magnesium concentrations were consistently <1 mmol/l across studies. Intravenous loading dose between 4 and 6 g was associated with a doubling of this baseline concentration half an hour after injection. Maintenance infusion of 1 g/hour consistently produced concentrations well below 2 mmol/l, whereas maintenance infusion at 2 g/hour and the Pritchard intramuscular regimen had higher but inconsistent probability of producing concentrations between 2 and 3 mmol/l. Volume of distribution of magnesium varied (13.65-49.00 l) but the plasma clearance was fairly similar (4.28-5.00 l/hour) across populations.

CONCLUSION

The profiles of Zuspan and Pritchard regimens indicate that the minimum effective serum magnesium concentration for eclampsia prophylaxis is lower than the generally accepted level. Exposure-response studies to identify effective alternative dosing regimens should target concentrations achievable by these standard regimens.

TWEETABLE ABSTRACT

Minimum effective serum magnesium concentration for eclampsia prophylaxis is lower than the generally accepted therapeutic level.

Network for Surveillance of Severe Maternal Morbidity: a powerful national collaboration generating data on maternal health outcomes and care

OBJECTIVE

To identify cases of severe maternal morbidity (SMM) during pregnancy and childbirth, their characteristics, and to test the feasibility of scaling up World Health Organization criteria for identifying women at risk of a worse outcome.

DESIGN

Multicentre cross-sectional study.

SETTING

Twenty-seven referral maternity hospitals from all regions of Brazil.

POPULATION

Cases of SMM identified among 82 388 delivering women over a 1-year period.

METHODS

Prospective surveillance using the World Health Organization's criteria for potentially life-threatening conditions (PLTC) and maternal near-miss (MNM) identified and assessed cases with severe morbidity or death.

MAIN OUTCOME MEASURES

Indicators of maternal morbidity and mortality; sociodemographic, clinical and obstetric characteristics; gestational and perinatal outcomes; main causes of morbidity and delays in care.

RESULTS

Among 9555 cases of SMM, there were 140 deaths and 770 cases of MNM. The main determining cause of maternal complication was hypertensive disease. Criteria for MNM conditions were more frequent as the severity of the outcome increased, all combined in over 75% of maternal deaths.

CONCLUSIONS

This study identified around 9.5% of MNM or death among all cases developing any severe maternal complication. Multicentre studies on surveillance of SMM, with organised collaboration and adequate study protocols can be successfully implemented, even in low-income and middle-income settings, generating important information on maternal health and care to be used to implement appropriate health policies and interventions.

TWEETABLE ABSTRACT

Surveillance of severe maternal morbidity was proved to be possible in a hospital network in Brazil.

A global reference for caesarean section rates (C-Model): a multicountry cross-sectional study

Objective

To generate a global reference for caesarean section (CS) rates at health facilities.

Design

Cross‐sectional study.

Setting

Health facilities from 43 countries.

Population/Sample

Thirty eight thousand three hundred and twenty‐four women giving birth from 22 countries for model building and 10 045 875 women giving birth from 43 countries for model testing.

Methods

We hypothesised that mathematical models could determine the relationship between clinical‐obstetric characteristics and CS. These models generated probabilities of CS that could be compared with the observed CS rates. We devised a three‐step approach to generate the global benchmark of CS rates at health facilities: creation of a multi‐country reference population, building mathematical models, and testing these models.

Main outcome measures

Area under the ROC curves, diagnostic odds ratio, expected CS rate, observed CS rate.

Results

According to the different versions of the model, areas under the ROC curves suggested a good discriminatory capacity of C‐Model, with summary estimates ranging from 0.832 to 0.844. The C‐Model was able to generate expected CS rates adjusted for the case‐mix of the obstetric population. We have also prepared an e‐calculator to facilitate use of C‐Model (www.who.int/reproductivehealth/publications/maternal_perinatal_health/c-model/en/).

Conclusions

This article describes the development of a global reference for CS rates. Based on maternal characteristics, this tool was able to generate an individualised expected CS rate for health facilities or groups of health facilities. With C‐Model, obstetric teams, health system managers, health facilities, health insurance companies, and governments can produce a customised reference CS rate for assessing use (and overuse) of CS.

Tweetable abstract

The C‐Model provides a customized benchmark for caesarean section rates in health facilities and systems.

The C‐Model provides a customized benchmark for caesarean section rates in health facilities and systems.

Effects of dietborne cadmium on life history and secondary production of a tropical freshwater cladoceran

The presence of metals in aquatic environments has increased worldwide. Environmental assessments of metals in freshwater ecosystems presume that toxicity is mainly caused by aqueous exposure, but dietborne exposure (contaminated food) in zooplankton may occur because microalgae carry metal ions through adsorption/absorption of dissolved metal species, resulting in toxic effects once ingested by the animals. However, official regulations for ecotoxicological assays in most countries do not consider the toxic effects caused by dietborne exposure. Here, we provide life history parameters and secondary production of Simocephalus serrulatus (Koch 1841) (Cladocera: Daphniidae) fed with cadmium (Cd) contaminated algae during a 21-day bioassay. The microalgae Chlorophyceae Scenedesmus quadricauda was exposed for 96 h to dissolved Cd concentrations of 0.03; 5.87; 12.27 and 22.27 µg Cd l(-1) (equivalent to 1.6 × 10(-10); 3.2 × 10(-8); 6.7 × 10(-8); 1.2 × 10(-7) mol l(-1)) that resulted in algae internal Cd burdens of 0.004; 0.032; 0.270 and 0.280 pg Cd cell(-1), respectively. Significant toxic effects on life history parameters of S. serrulatus were observed. Time of embryonic development, generation time and age at first reproduction (primipara) showed significant delay. Length at first reproduction, number of eggs and clutches produced per female, hatching percentage, body length, survival and feeding rates were significantly reduced. Secondary production, that is, accumulated biomass for growth and reproduction, decreased significantly with dietborne Cd concentrations. Our results emphasize that food can be an important source of metals to zooplankton in aquatic ecosystems. Environmental regulations should consider the diet in ecotoxicological assessments. Furthermore, secondary production may be considered as a suitable endpoint in ecotoxicity tests.

Education and severe maternal outcomes in developing countries: a multicountry cross-sectional survey

OBJECTIVE

To assess the relationship between education and severe maternal outcomes among women delivering in healthcare facilities.

DESIGN

Cross-sectional study.

SETTING

Twenty-nine countries in Africa, Asia, Latin America, and the Middle East.

POPULATION

Pregnant women admitted to 359 facilities during a period of 2-4 months of data collection between 2010 and 2011.

METHODS

Data were obtained from hospital records. Stratification was based on the Human Development Index (HDI) values of the participating countries. Multivariable logistic regression analyses were conducted to assess the association between maternal morbidity and education, categorised in quartiles based on the years of formal education by country. Coverage of key interventions was assessed.

MAIN OUTCOME MEASURES

Severe maternal outcomes (near misses and death).

RESULTS

A significant association between low education and severe maternal outcomes (adjusted odds ratio, aOR, 2.07; 95% confidence interval, 95% CI, 1.46-2.95), maternal near miss (aOR 1.80; 95% CI 1.25-2.57), and maternal death (aOR 5.62; 95% CI 3.45-9.16) was observed. This relationship persisted in countries with medium HDIs (aOR 2.36; 95% CI 1.33-4.17) and low HDIs (aOR 2.65; 95% CI 1.54-2.57). Less educated women also had increased odds of presenting to the hospital in a severe condition (i.e. with organ dysfunction on arrival or within 24 hours: aOR 2.06; 95% CI 1.36-3.10). The probability that a woman received magnesium sulphate for eclampsia or had a caesarean section significantly increased as education level increased (P < 0.05).

CONCLUSIONS

Women with lower levels of education are at greater risk for severe maternal outcomes, even after adjustment for key confounding factors. This is particularly true for women in countries that have poorer markers of social and economic development.

Maternal and institutional characteristics associated with the administration of prophylactic antibiotics for caesarean section: a secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health

OBJECTIVE

To illustrate the variability in the use of antibiotic prophylaxis for caesarean section, and its effect on the prevention of postoperative infections.

DESIGN

Secondary analysis of a cross-sectional study.

SETTING

Twenty-nine countries participating in the World Health Organization Multicountry Survey on Maternal and Newborn Health.

POPULATION

Three hundred and fifty-nine health facilities with the capacity to perform caesarean section.

METHODS

Descriptive analysis and effect estimates using multilevel logistic regression.

MAIN OUTCOME MEASURES

Coverage of antibiotic prophylaxis for caesarean section.

RESULTS

A total of 89 121 caesarean sections were performed in 332 of the 359 facilities included in the survey; 87% under prophylactic antibiotic coverage. Thirty five facilities provided 0-49% coverage and 77 facilities provided 50-89% coverage. Institutional coverage of prophylactic antibiotics varied greatly within most countries, and was related to guideline use and the practice of clinical audits, but not to the size, location of the institution or development index of the country. Mothers with complications, such as HIV infection, anaemia, or pre-eclampsia/eclampsia, were more likely to receive antibiotic prophylaxis. At the same time, mothers undergoing caesarean birth prior to labour and those with indication for scheduled deliveries were also more likely to receive antibiotic prophylaxis, despite their lower risk of infection, compared with mothers undergoing emergency caesarean section.

CONCLUSIONS

Coverage of antibiotic prophylaxis for caesarean birth may be related to the perception of the importance of guidelines and clinical audits in the facility. There may also be a tendency to use antibiotics when caesarean section has been scheduled and antibiotic prophylaxis is already included in the routine clinical protocol. This study may act as a signal to re-evaluate institutional practices as a way to identify areas where improvement is possible.

Risk factors for spontaneous and provider-initiated preterm delivery in high and low Human Development Index countries: a secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health

OBJECTIVE

To evaluate how the effect of maternal complications on preterm birth varies between spontaneous and provider-initiated births, as well as among different countries.

DESIGN

Secondary analysis of a cross-sectional study.

SETTING

Twenty-nine countries participating in the World Health Organization Multicountry Survey on Maternal and Newborn Health.

POPULATION

299 878 singleton deliveries of live neonates or fresh stillbirths.

METHODS

Countries were categorised into very high, high, medium and low developed countries using the Human Development Index (HDI) of 2012 by the World Bank. We described the prevalence and risk of maternal complications, their effect on outcomes and their variability by country development.

MAIN OUTCOME MEASURES

Preterm birth, fresh stillbirth and early neonatal death.

RESULTS

The proportion of provider-initiated births among preterm deliveries increased with development: 19% in low to 40% in very high HDI countries. Among preterm deliveries, the socially disadvantaged were less likely, and the medically high risk were more likely, to have a provider-initiated delivery. The effects of anaemia [adjusted odds ratio (AOR), 2.03; 95% confidence interval (CI), 1.84; 2.25], chronic hypertension (AOR, 2.28; 95% CI, 1.94; 2.68) and pre-eclampsia/eclampsia (AOR, 5.03; 95% CI, 4.72; 5.37) on preterm birth were similar among all four HDI subgroups.

CONCLUSIONS

The provision of adequate obstetric care, including optimal timing for delivery in high-risk pregnancies, especially to the socially disadvantaged, could improve pregnancy outcomes. Avoiding preterm delivery in women when maternal complications, such as anaemia or hypertensive disorders, are present is important for countries at various stages of development, but may be more challenging to achieve.

Pre-eclampsia, eclampsia and adverse maternal and perinatal outcomes: a secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health

OBJECTIVE

To assess the incidence of hypertensive disorders of pregnancy and related severe complications, identify other associated factors and compare maternal and perinatal outcomes in women with and without these conditions.

DESIGN

Secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health (WHOMCS) database.

SETTING

Cross-sectional study implemented at 357 health facilities conducting 1000 or more deliveries annually in 29 countries from Africa, Asia, Latin America and the Middle East.

POPULATION

All women suffering from any hypertensive disorder during pregnancy, the intrapartum or early postpartum period in the participating hospitals during the study period.

METHODS

We calculated the proportion of the pre-specified outcomes in the study population and their distribution according to hypertensive disorders' severity. We estimated the association between them and maternal deaths, near-miss cases, and severe maternal complications using a multilevel logit model.

MAIN OUTCOME MEASURES

Hypertensive disorders of pregnancy. Potentially life-threatening conditions among maternal near-miss cases, maternal deaths and cases without severe maternal outcomes.

RESULTS

Overall, 8542 (2.73%) women suffered from hypertensive disorders. Incidences of pre-eclampsia, eclampsia and chronic hypertension were 2.16%, 0.28% and 0.29%, respectively. Maternal near-miss cases were eight times more frequent in women with pre-eclampsia, and increased to up to 60 times more frequent in women with eclampsia, when compared with women without these conditions.

CONCLUSIONS

The analysis of this large database provides estimates of the global distribution of the incidence of hypertensive disorders of pregnancy. The information on the most frequent complications related to pre-eclampsia and eclampsia could be of interest to inform policies for health systems organisation.

Advanced maternal age and pregnancy outcomes: a multicountry assessment

OBJECTIVE

To assess the association between advanced maternal age (AMA) and adverse pregnancy outcomes.

DESIGN

Secondary analysis of the facility-based, cross-sectional data of the WHO Multicountry Survey on Maternal and Newborn Health.

SETTINGS

A total of 359 health facilities in 29 countries in Africa, Asia, Latin America, and the Middle East.

SAMPLE

A total of 308 149 singleton pregnant women admitted to the participating health facilities.

METHODS

We estimated the prevalence of pregnant women with advanced age (35 years or older). We calculated adjusted odds ratios of individual severe maternal and perinatal outcomes in these women, compared with women aged 20-34 years, using a multilevel, multivariate logistic regression model, accounting for clustering effects within countries and health facilities. The confounding factors included facility and individual characteristics, as well as country (classified by maternal mortality ratio level).

MAIN OUTCOME MEASURES

Severe maternal adverse outcomes, including maternal near miss (MNM), maternal death (MD), and severe maternal outcome (SMO), and perinatal outcomes, including preterm birth (<37 weeks of gestation), stillbirths, early neonatal mortality, perinatal mortality, low birthweight (<2500 g), and neonatal intensive care unit (NICU) admission.

RESULTS

The prevalence of pregnant women with AMA was 12.3% (37 787/308 149). Advanced maternal age significantly increased the risk of maternal adverse outcomes, including MNM, MD, and SMO, as well as the risk of stillbirths and perinatal mortalities.

CONCLUSIONS

Advanced maternal age predisposes women to adverse pregnancy outcomes. The findings of this study would facilitate antenatal counselling and management of women in this age category.

Mode and timing of twin delivery and perinatal outcomes in low- and middle-income countries: a secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health

OBJECTIVE

To describe the mode and timing of delivery of twin pregnancies at ≥34 weeks of gestation and their association with perinatal outcomes.

DESIGN

Secondary analysis of a cross-sectional study.

POPULATION

Twin deliveries at ≥34 weeks of gestation from 21 low- and middle-income countries participating in the WHO Multicountry Survey on Maternal and Newborn Health.

METHODS

Descriptive analysis and effect estimates using multilevel logistic regression.

MAIN OUTCOME MEASURES

Stillbirth, perinatal mortality, and neonatal near miss (use of selected life saving interventions at birth).

RESULTS

The average length of gestation at delivery was 37.6 weeks. Of all twin deliveries, 16.8 and 17.6% were delivered by caesarean section before and after the onset of labour, respectively. Prelabour caesarean delivery was associated with older maternal age, higher institutional capacity and wealth of the country. Compared with spontaneous vaginal delivery, lower risks of neonatal near miss (adjusted odds ratio, aOR, 0.63; 95% confidence interval, 95% CI, 0.44-0.94) were found among prelabour caesarean deliveries. A lower risk of early neonatal mortality (aOR 0.12; 95% CI 0.02-0.56) was also observed among prelabour caesarean deliveries with nonvertex presentation of the first twin. The week of gestation with the lowest rate of prospective fetal death varied by fetal presentation: 37 weeks for vertex-vertex; 39 weeks for vertex-nonvertex; and 38 weeks for a nonvertex first twin.

CONCLUSIONS

The prelabour caesarean delivery rate among twins varied largely between countries, probably as a result of overuse of caesarean delivery in wealthier countries and limited access to caesarean delivery in low-income countries. Prelabour delivery may be beneficial when the first twin is nonvertex. International guidelines for optimal twin delivery methods are needed.

Maternal and perinatal outcomes among nulliparous adolescents in low- and middle-income countries: a multi-country study

OBJECTIVE

To investigate the risk of adverse pregnancy outcomes and caesarean section among adolescents in low- and middle-income countries.

DESIGN

Secondary analysis using facility-based cross-sectional data from the World Health Organization (WHO) Global Survey on Maternal and Perinatal Health.

SETTING

Twenty-three countries in Africa, Latin America, and Asia.

POPULATION

Women admitted for delivery in 363 health facilities during 2-3 months between 2004 and 2008.

METHODS

We constructed multilevel logistic regression models to estimate the effect of young maternal age on risks of adverse pregnancy outcomes.

MAIN OUTCOME MEASURES

Risk of adverse pregnancy outcomes among young mothers.

RESULTS

A total of 78 646 nulliparous mothers aged ≤24 years and their singleton infants were included in the analysis. Compared with mothers aged 20-24 years, adolescents aged 16-19 years had a significantly lower risk of caesarean section (adjusted OR 0.75, 95% CI 0.71-0.79). When the analysis was restricted to caesarean section indicated for presumed cephalopelvic disproportion, the risk of caesarean section was significantly higher among mothers aged ≤15 years (aOR 1.27, 95% CI 1.07-1.49) than among those aged 20-24 years. Higher risks of low birthweight and preterm birth were found among adolescents aged 16-19 years (aOR 1.10, 95% CI 1.03-1.17; aOR 1.16, 95% CI 1.09-1.23, respectively) and ≤15 years (aOR 1.33, 95% CI 1.14-1.54; aOR 1.56, 95% CI 1.35-1.80, respectively).

CONCLUSIONS

Adolescent girls experiencing pregnancy at a very young age (i.e. <16 years) have an increased risk of adverse pregnancy outcomes.

OS029. Severe anemia, sickle cell disease, and thalassemia as riskfactors for preeclampsia in developing countries

INTRODUCTION

Hypertensive disorders during pregnancy contribute greatly to maternal and perinatal morbidity and mortality in developing countries. The pathogenesis of such conditions may be illuminated by exploring their relationship to anemia.

OBJECTIVES

To determine whether several types of anemia are risk factors for hypertensive disorders during pregnancy in developing countries.

METHODS

Using data from the World Health Organization Global Survey for Maternal and Perinatal Health, collected in hospitals in six African and six Latin American countries from 2007 to 2008 and in four Asian countries from 2004 to 2005, we examined the associations between severe anemia, sickle cell disease and thalassemia and gestational hypertension or preeclampsia/eclampsia. After exclusions for comorbidities (chronic hypertension, diabetes, HIV infection) and missing data, the severe anemia, sickle cell disease, and thalassemia groups consisted of 219,627,117,383, and 9376 women, respectively.

RESULTS

Multiparous women with severe anemia were at an increased risk of gestational hypertension (adjusted odds ratio (OR): 1.58; 95% confidence interval (CI): 1.15-2.19). Severe anemia had a significant association with preeclampsia/eclampsia for nulliparous (OR: 3.55; 95% CI: 2.87-4.41) and multiparous (OR: 3.94; 95% CI: 3.05-5.09) women. Sickle cell disease exhibited a significant association with gestational hypertension among nulliparous (OR: 2.49; 95% CI: 1.46-4.25) and multiparous (OR: 3.27; 95% CI: 2.33-4.58) women. No significant associations were found between sickle cell disease and preeclampsia/eclampsia, or between thalassemia and either gestational hypertension or preeclampsia/eclampsia.

CONCLUSION

Severe anemia appears to be a risk factor for preeclampsia/eclampsia, while sickle cell disease appears to be a risk factor for gestational hypertension among women seeking hospital care in developing countries.

Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the 2004-2008 WHO Global Survey on Maternal and Perinatal Health

BACKGROUND

There is worldwide debate about the appropriateness of caesarean sections performed without medical indications. In this analysis, we aim to further investigate the relationship between caesarean section without medical indication and severe maternal outcomes.

METHODS

This is a multicountry, facility-based survey that used a stratified multistage cluster sampling design to obtain a sample of countries and health institutions worldwide. A total of 24 countries and 373 health facilities participated in this study. Data collection took place during 2004 and 2005 in Africa and the Americas and during 2007 and 2008 in Asia. All women giving birth at the facility during the study period were included and had their medical records reviewed before discharge from the hospital. Univariate and multilevel analysis were performed to study the association between each group's mode of delivery and the severe maternal and perinatal outcome.

RESULTS

A total of 286,565 deliveries were analysed. The overall caesarean section rate was 25.7% and a total of 1.0 percent of all deliveries were caesarean sections without medical indications, either due to maternal request or in the absence of other recorded indications. Compared to spontaneous vaginal delivery, all other modes of delivery presented an association with the increased risk of death, admission to ICU, blood transfusion and hysterectomy, including antepartum caesarean section without medical indications (Adjusted Odds Ratio (Adj OR), 5.93, 95% Confidence Interval (95% CI), 3.88 to 9.05) and intrapartum caesarean section without medical indications (Adj OR, 14.29, 95% CI, 10.91 to 18.72). In addition, this association is stronger in Africa, compared to Asia and Latin America.

CONCLUSIONS

Caesarean sections were associated with an intrinsic risk of increased severe maternal outcomes. We conclude that caesarean sections should be performed when a clear benefit is anticipated, a benefit that might compensate for the higher costs and additional risks associated with this operation.

Maternal morbidity and near miss in the community: findings from the 2006 Brazilian demographic health survey

OBJECTIVE

To obtain an estimate of the prevalence of potentially life-threatening maternal conditions and near-miss events in Brazil, and to explore the factors associated with these complications.

DESIGN

A demographic health survey (DHS) focusing on reported maternal complications.

SETTING

Data from the five geographical regions of Brazil.

POPULATION

A total of 5025 women with at least one live birth in the 5-year reference period preceding their interview in the DHS.

METHODS

A secondary analysis of the 2006 Brazilian DHS database was carried out using a validated questionnaire to evaluate the occurrence of maternal complications and related key interventions. According to a pragmatic definition, any woman reporting the occurrence of eclampsia, hysterectomy, blood transfusion or admission to the intensive care unit was considered as having experienced a near-miss event. Associations between the sociodemographic characteristics of the women and severe maternal morbidity were evaluated.

MAIN OUTCOME MEASURES

Proportions and ratios of complications and related interventions defined as maternal near miss in pregnancy, and estimated risk factors for maternal morbidities.

RESULTS

Around 22% of women reported complications during pregnancy. The prevalence of maternal near miss in Brazil, using the pragmatic definition, was 21.1 per 1000 live births. An increased risk of severe maternal morbidity was found in women aged ≥40 years and in those with low levels of education.

CONCLUSIONS

Nearly 70,000 maternal near-miss cases and approximately 750,000 cases with potentially life-threatening conditions are estimated to occur in Brazil per year. A pragmatic definition of maternal near miss was useful to obtain more reliable information at the community level. This approach could be used to gather information on maternal morbidity in settings in which such data are not routinely collected.

Factors and outcomes associated with the induction of labour in Latin America

OBJECTIVE

To describe the prevalence of labour induction, together with its risk factors and outcomes in Latin America.

DESIGN

Analysis of the 2005 WHO global survey database.

SETTING

Eight selected Latin American countries.

POPULATION

All women who gave birth during the study period in 120 participating institutions.

METHODS

Bivariate and multivariate analyses.

MAIN OUTCOME MEASURES

Indications for labour induction per country, success rate per method, risk factors for induction, and maternal and perinatal outcomes.

RESULTS

Of the 97,095 deliveries included in the survey, 11,077 (11.4%) were induced, with 74.2% occurring in public institutions, 20.9% in social security hospitals and 4.9% in private institutions. Induction rates ranged from 5.1% in Peru to 20.1% in Cuba. The main indications were premature rupture of membranes (25.3%) and elective induction (28.9%). The success rate of vaginal delivery was very similar for oxytocin (69.9%) and misoprostol (74.8%), with an overall success rate of 70.4%. Induced labour was more common in women over 35 years of age. Maternal complications included higher rates of perineal laceration, need for uterotonic agents, hysterectomy, ICU admission, hospital stay>7 days and increased need for anaesthetic/analgesic procedures. Some adverse perinatal outcomes were also higher: low 5-minute Apgar score, very low birthweight, admission to neonatal ICU and delayed initiation of breastfeeding.

CONCLUSIONS

In Latin America, labour was induced in slightly more than 10% of deliveries; success rates were high irrespective of the method used. Induced labour is, however, associated with poorer maternal and perinatal outcomes than spontaneous labour.

Appropriate criteria for identification of near-miss maternal morbidity in tertiary care facilities: a cross sectional study

Background

The study of severe maternal morbidity survivors (near miss) may be an alternative or a complement to the study of maternal death events as a health care indicator. However, there is still controversy regarding the criteria for identification of near-miss maternal morbidity. This study aimed to characterize the near miss maternal morbidity according to different sets of criteria.

Methods

A descriptive study in a tertiary center including 2,929 women who delivered there between July 2003 and June 2004. Possible cases of near miss were daily screened by checking different sets of criteria proposed elsewhere. The main outcome measures were: rate of near miss and its primary determinant factors, criteria for its identification, total hospital stay, ICU stay, and number and kind of special procedures performed.

Results

There were two maternal deaths and 124 cases of near miss were identified, with 102 of them admitted to the ICU (80.9%). Among the 126 special procedures performed, the most frequent were central venous access, echocardiography and invasive mechanical ventilation. The mean hospital stay was 10.3 (± 13.24) days. Hospital stay and the number of special procedures performed were significantly higher when the organ dysfunction based criteria were applied.

Conclusion

The adoption of a two level screening strategy may lead to the development of a consistent severe maternal morbidity surveillance system but further research is needed before worldwide near miss criteria can be assumed.

Predictors of preterm birth

OBJECTIVE

This is a systematic review to assess published scientific evidence on preterm birth predictors.

METHODS

An Internet search for predictors of preterm birth was performed and the evidence level of each method was evaluated.

RESULTS

There is strong evidence that preterm birth can be predicted using vaginal sonography to evaluate cervical characteristics, fetal fibronectin in cervicovaginal secretions and interleukin-6 in amniotic fluid. There is consistent evidence that digital cervical examination is a weak predictor, and controversy regarding home uterine activity monitoring. There is scanty evidence about the predictive ability of maternal history and perceptions of symptoms since the study design fails to provide high evidence level.

CONCLUSION

Cervical evaluation by vaginal sonography, fetal fibronectin and interleukin-6 are the best methods for predicting preterm birth.

Assessment of menstrual blood loss in Brazilian users of the frameless copper-releasing IUD with copper surface area of 330 mm2 and the frameless levonorgestrel-releasing intrauterine system

OBJECTIVE

This study was conducted to evaluate the effect of two types of IUDs on the amount of menstrual blood loss (MBL): the frameless copper-releasing intrauterine device (IUD) with copper surface area of 330 mm2 (GyneFix; Contrel Research, Ghent, Belgium) and the frameless levonorgestrel (LNG)-releasing intrauterine system (IUS) releasing 14 microg per day (FibroPlant-LNG; Contrel Research). Heavy and abnormal MBL is the main reason for discontinuation of intrauterine devices.

METHODS

In 20 Brazilian women using GyneFix 330 and 32 using FibroPlant-LNG, respectively, MBL was measured by the quantitative alkaline hematin technique. In addition, ferritin levels were measured in GyneFix 330 and FibroPlant-LNG users.

RESULTS

MBL with GyneFix 330, measured over a 24-month period, increased but was less when compared with TCu380A. Ferritin levels with GyneFix 330 were not affected in contrast with TCu380A. In FibroPlant-LNG users, mean MBL decreased by about 90% and ferritin levels increased significantly.

CONCLUSIONS

The authors confirm earlier reports that, especially for women with low body iron stores and heavy menstrual bleeding, there is an order of preference for IUD use to minimize MBL. The choice should first be a progestin-releasing IUS, then a copper IUD, which has the least effect on menstrual bleeding, such as the frameless GyneFix IUD.

Controlled trial of inhaled fluticasone propionate in moderate to severe COPD

Inhaled corticosteroids are often used in the treatment of stable chronic obstructive pulmonary disease (COPD), however, studies of these agents have had mixed results. Previous trials have often excluded subjects with bronchodilator response, have failed to evaluate effect on gas exchange, and have usually looked at only post- rather than prebronchodilator forced expiratory volume (FEV). Our objective was to better assess the efficacy of topical corticosteroids in the treatment of COPD. We used a prospective, randomized, double-blinded, placebo-controlled, crossover study at the Outpatient Department, Department of Veterans Affairs Medical Center. Thirty-six COPD patients with a mean (+/- SD) FEV1 of 1.10 +/- 0.43 L, with or without significant bronchodilator response participated in the study. Subjects received a 3-month course of inhaled fluticasone propionate (220 micro g/puff) or identical-appearing placebo by metered-dose inhaler at 2 puffs twice daily, followed by crossover to the alternative inhaler for an additional 3 months. Fluticasone treatment resulted in a higher prebronchodilator FEV1 (1.17 +/- 0.08 L [mean +/- SEM] versus 1.07 +/- 0.08 L, p = 0.001), a higher PaO2 (66.6 +/- 1.4 mmHg versus 63.6 +/- 1.6 mmHg, p = 0.002), and a better dyspnea score on the chronic respiratory questionnaire (3.70 +/- 0.18 versus 3.47 +/- 0.19, p = 0.03). A trend towards fewer exacerbations with fluticasone did not quite meet statistical significance (p = 0.11). Inhaled fluticasone over 3 months improved prebronchodilator airflow obstruction and oxygenation while decreasing dyspnea in moderate to severe COPD. Postbronchodilator FEV1 was not significantly changed.

Effect of expiratory resistive loading on the noninvasive tension-time index in COPD

Expiratory resistive loading (ERL) is used by chronic obstructive pulmonary disease (COPD) patients to improve respiratory function. We, therefore, used a noninvasive tension-time index of the inspiratory muscles (TT(mus) = I/PI(max) x TI/TT, where I is mean inspiratory pressure estimated from the mouth occlusion pressure, PI(max) is maximal inspiratory pressure, TI is inspiratory time, and TT is total respiratory cycle time) to better define the effect of ERL on COPD patients. To accomplish this, we measured airway pressures, mouth occlusion pressure, respiratory cycle flow rates, and functional residual capacity (FRC) in 14 COPD patients and 10 normal subjects with and without the application of ERL. TT(mus) was then calculated and found to drop in both COPD and normal subjects (P<0.05). The decline in TT(mus) in both groups resulted solely from a prolongation of expiratory time with ERL (P<0.001 for COPD, P<0.05 for normal subjects). In contrast to the COPD patients, normal subjects had an elevation in I and FRC, thus minimizing the decline in TT(mus). In conclusion, ERL reduces the potential for inspiratory muscle fatigue in COPD by reducing TI/TT without affecting FRC and I.

High rates of Pneumocystis carinii pneumonia in allogeneic blood and marrow transplant recipients receiving dapsone prophylaxis

Chemoprophylaxis for Pneumocystis carinii pneumonia (PCP) is routinely given after allogeneic blood or marrow transplantation. We evaluated the effectiveness of dapsone prophylaxis (50 mg orally twice daily, 3 times per week) compared with twice-weekly trimethoprim-sulfamethoxazole (TMP-SMZ) in preventing PCP after allogeneic blood or marrow transplantation. Patients included all (n=646) who received allogeneic blood or marrow transplants between 1 September 1993 and 31 December 1996 who survived at least 100 days after transplantation. A cohort of 111 dapsone recipients was compared with the remaining 535 who received TMP-SMZ. Ten patients developed PCP; 8 were taking dapsone. PCP incidence in the TMP-SMZ cohort was 0.37% versus 7.2% for dapsone. The relative risk for PCP associated with dapsone use was 18.8 (P<.001) and was not accounted for by age, clinical extensive chronic graft-versus-host disease, donor source, or malignant relapse. Dapsone prophylaxis at this dosage is associated with significantly higher rates of PCP than is TMP-SMZ after allogeneic marrow transplantation. We advise caution in prescribing alternatives to TMP-SMZ prophylaxis in this setting.

Menstrual blood loss and body iron stores in Brazilian women

Menstrual blood loss (MBL) studies are relevant for developing world women as this could be an important cause of anemia. Whenever a contraceptive method is to be used by such women, consideration should be given to the method which least affects the volume of MBL. In 309 women considered as clinically healthy, MBL, serum ferritin, serum iron and hemoglobin levels were measured: a mean MBL of 23 ml was found. Age, weight, height and previous oral contraceptive use did not affect MBL. Higher parity women may have higher MBL levels but their hematologic indices are not altered. While body iron stores (as judged by serum ferritin levels) are depleted in women who bleed more than 60 ml per cycle, clinical anemia may not be present until their blood loss exceeds 80 ml per menstruation. Brazilian women who lose more than 60 ml of menstrual blood associated with multiple pregnancies without adequate iron supplementation may have a depletion of their body iron stores.

An anatomic comparison of cebocephaly and ethmocephaly

Cebocephaly (hypotelorism, single-nostril nose) and ethmocephaly (hypotelorism, interorbital proboscis) lie in the middle of the spectrum of craniofacial changes associated with holoprosencephaly. Because these defects and thorough anatomic studies of them are rare, knowledge concerning morphologic as well as pathogenetic relationships is lacking. We report the autopsy findings and anatomic features of the dried skull of a 31 week fetus with cebocephaly and the craniofacial dissection of a 36 week fetus with ethmocephaly. Both manifested dysplastic changes of the ethmoid bone and anterior portion of the sphenoid bone, with concomitant hypotelorism and defects of the medial orbital walls. Through these latter defects, the eyes were joined in the ethmocephalic fetus (synophthalmia). Other changes of bone (single optic foramen, approximated maxillae, choanal atresia, thickened palate) and soft tissue (eccentric or fused extraocular muscles, single optic nerve) in both fetuses resembled those reported in other cases of cebocephaly and ethmocephaly, as well as cyclopia. In the 19th century, both cebocephaly and ethmocephaly were classified as two-orbit variants of cyclopia, a view supported by the present study.