An ethical framework for evaluation of public health plans: a systematic process for legitimate and fair decision-making

OBJECTIVES

Given the increasing threats of communicable and non-communicable diseases, it is necessary for policy-makers and public health (PH) professionals to address ethical issues in health policies and plans. This study aimed to develop a practical framework for the ethical evaluation of PH programs.

STUDY DESIGN

A multidisciplinary team developed an ethical framework to evaluate PH plans from 2015 to 2017.

METHODS

In this study, the multi-method approach was used. First, a list of moral norms in PH policy and practice was drafted and completed in two interactive sessions. Then, the Delphi method was used for consensus about the structural components to be adopted in the framework. After developing the framework, its efficiency was assessed by evaluating Iran's Fourth Strategic Plan for HIV/AIDS Prevention and Control.

RESULTS

The framework was developed in the following three sections: (i) determination of the general moral norms in PH practice and policy; (ii) five steps of evaluation; and (iii) a procedural evaluation step to ensure fair decision-making. The ratio of the ethical points of the PH plan increased by 46% after implementation of the framework, and the frequency of ethical points increased significantly after applying the framework (P = 0.001).

CONCLUSION

The application of the framework for the ethical evaluation of various PH programs ensures a comprehensive and scientific-deliberative decision-making process, while also contributing to the development of the framework.

Estimated incidence of cardiac contusion using transthoracic echocardiography in patients suffering from severe blunt trauma to the chest

BACKGROUND

Cardiac contusion (CC) is a known complication of blunt trauma to the chest. There have been debates about its true incidence and there are different reports which claim that it occurs in less than 10% to more than 70% of patients. The goal of this study is to estimate the incidence of CC in patients with severe blunt chest trauma (SBCT) using transthoracic echocardiography (TTE).

METHODS

After defining inclusion and exclusion criteria, all cases with clinical evidences of SBCT from February 2010 until October 2011 were included in this study. Patients were assessed using electrocardiography (ECG) and transthoracic echocardiography (TTE). Transient echocardiographic changes, including wall motion abnormalities, valvular or papillary muscle dysfunction, pericardial effusion or tamponade, free wall rupture and interatrial/interventricular septum defects, were considered to be abnormal and trauma-related.

RESULTS

A total of 210 patients were assessed for CC. Fifty-two trauma-related echocardiographic changes in 47 patients were observed, in which 34 cases had simultaneous transient ECG changes. The estimated incidence of CC in these subjects was calculated to be 23.38% and 16.19%, respectively. There was a statistically significant relationship between the presence of both echocardiographic changes and ECG abnormalities, and those subjects without ECG changes (P = 0.03). As we evaluated stable patients without any cardiac-related clinical manifestations and TTE was chosen as our diagnostic modality, we claim that the true incidence must be higher.

CONCLUSIONS

We believe that a comparison of our findings with those presented in the literature shows that the actual incidence of CC in blunt chest trauma is underestimated.

Cervical cerclage for prevention of preterm birth in women with twin pregnancy

OBJECTIVE

To compare the effect of elective cervical cerclage in women with twin pregnancy on gestational age at time of delivery.

METHOD

In a pragmatic fashion women in Abha Maternity Hospital, Saudi Arabia with twin gestations were allocated to receive either an elective cerclage (group I) or no cerclage (group II). Elective cerclage was performed at 12 to 14 weeks of gestation after sonographic examination of the fetus to confirm gestational age and exclude major congenital anomalies. In all cases, follow up of the pregnancy was continued until delivery.

RESULTS

Of the 176 twin pregnancies included, cerclage was performed in 76 women, and no cerclage in 100 women. In Group I: 12 pregnancies ended in spontaneous miscarriage, 37 in preterm labor, and 27 women reached full term. There were a total of 106 live births in 62 women. In Group II: 8 women aborted, 44 women ended in preterm labor and 48 women reached full term. There were a total of 160 live births in 89 women. The gestational age at delivery ranged from 20 to 41 weeks. Multiple regression analysis did not show association between cerclage and time of delivery, although a trend was observed (P=0.056).

CONCLUSION

Elective cerclage contributes little in prolongation of gestational age at the time of delivery in women with twin pregnancy, especially in women of high parity. Those with a previous history of preterm labor may be a subgroup that could benefit from elective cerclage.

Induction of labour using low and high dose regimens of prostaglandin E2 vaginal tablets

OBJECTIVE

To compare the efficacy of low dose prostaglandin E2 vaginal tablets with that of high dose in induction of labour.

DESIGN

A retrospective study.

SETTING

Abha Maternity Hospital, a teaching hospital in the southern region of Saudia Arabia.

PATIENTS

The outcome of induction of labour in 73 women induced with 1.5 mg prostaglandin E2 vaginal tablets was compared with those in 168 women induced with 3 mg vaginal tablets.

RESULTS

There were no statistical significant differences in the success rate, induction-delivery interval, caesarean section rate and Apgar scores between the two groups. There were two incidences of uterine hyperstimulation and two of uterine rupture in the high dose group. These were not statistically significant. Logistic regression analysis showed that the success rate of induction of labour was dependent only on maternal age (P=0.0025) and Bishop score (P=-0.0403) and not on parity, gestational age, birthweight or dose of prostaglandin.

CONCLUSION

The low dose regimen of 1.5 mg is as efficacious as the high dose regimen of 3 mg prostaglandin E2 vaginal tablets in inducing labour. This implies that using the low dose regimen reduces the cost of induction of labour effectively. Larger prospective randomized studies are needed to confirm this finding.

Risk factors and morbidity in patients with placenta previa accreta compared to placenta previa non-accreta

BACKGROUND

Placenta accreta is associated with high morbidity and most cases occur with placenta previa. This study was carried out in an attempt to define risk factors for placenta accreta in cases of placenta previa and to quantify the increased morbidity of placenta previa accreta in comparison to placenta previa alone.

METHODS

The records of all patients delivered by cesarean section (CS) for placenta previa and accreta during the seven-year period from 1990 to 1996, inclusive, were reviewed. Data regarding the demographic features, previous CS, the incidence of hysterectomy and postpartum morbidity were analyzed.

RESULTS

Out of 23070 deliveries 110 (0.48%) had placenta previa, twelve (0.05%) of whom had placenta previa accreta. There was no significant difference in age and parity. Patients with a history of previous CS showed a significant increase in the incidence of placenta previa accreta (p=0.001). The percentage of accreta increased linearly from 4.1% in patients with no CS to 60% in patients who had had three or more CS. Postpartum hemorrhage and emergency hysterectomy were significantly higher among the previa accreta patients compared with the previa patients alone (p<0.001; p<0.001, respectively).

CONCLUSION

In the presence of a previous history of CS, patients with antepartum diagnosis of placenta previa are considered to be at a greater risk for having placenta accreta. The risk increases with the increase in the number of previous CS. Patients with placenta previa accreta have a significantly higher incidence of PPH and are more likely to undergo emergency hysterectomy.

Ultrasound appearance of a developing mole

A 40-year-old primigravida at her 9th week of pregnancy presented with uterine bleeding and an ultrasound picture of a non-embryonic pregnancy with an empty gestational sac but a thickened base of high echogenicity. A week later this thickened area showed a placenta-like disc with a picture of early molar change. At ultrasound follow-up, this progressed to a full hydatidiform mole filling the whole of the uterine cavity; the empty gestational sac had disappeared. The molar pregnancy was confirmed histologically following suction evacuation of the uterus. Early ultrasound diagnosis of a non-embryonic pregnancy or a blighted ovum may not rule out the presence of abnormal trophoblast associated with hydatidiform mole. Failed early pregnancies should be evacuated immediately once diagnosed.

Risk factors and fetal outcome in cases of shoulder dystocia compared with normal deliveries of a similar birthweight

OBJECTIVES

To compare risk factors and fetal morbidity in deliveries complicated by shoulder dystocia with deliveries of similar infant birthweights but not complicated by shoulder dystocia.

DESIGN

A retrospective case-controlled study.

SETTING

Kuwait Maternity Hospital.

PARTICIPANTS

Sixty-nine cases of true shoulder dystocia and 138 controls matched for exact infant's birthweight.

METHODS

Demographic data and data regarding history of previous shoulder dystocia, diabetes mellitus, labour course, method of delivery and newborns' condition were collected from patients and case notes following delivery. The mothers' height and weight were measured. Oral glucose tolerance test were performed on patients who were not known as diabetics. The infants' head and chest circumferences and bisacromial diameter were measured.

RESULTS

There were no significant differences between cases and controls when mean age, parity, height, weight and gestational ages were compared. The cases demonstrated a higher incidence of previous shoulder dystocia (P < 0.01), diabetes mellitus (P < 0.001), use of oxytocin for acceleration of labour (P < 0.01) and operative vaginal deliveries (P < 0.01). Differences between cases and controls in their newborn infants' head and chest circumferences were not significant, but the newborns of cases have a longer mean bisacromial diameter and a shorter head circumference:bisacromial diameter ratio (P < 0.001 and P < 0.001, respectively). Thirty-seven infants (53.6%) from cases and two from controls (1.4%) sustained birth injuries. There were two stillbirths among the cases.

CONCLUSIONS

Although fetal macrosomia is the principal risk factor for shoulder dystocia, other important risk factors include diabetes mellitus, previous history of shoulder dystocia, prolonged labour, delay in the second stage of labour and fetal shoulder width which appear to be independent of fetal weight.

Anticardiolipin and antinuclear antibodies in patients with unexplained recurrent abortions

In a controlled study on a resident population in Kuwait, 103 patients with unexplained recurrent spontaneous abortions were investigated for the frequency of positive tests for anticardiolipin antiobodies (ACA) and antinuclear antibodies (ANA). The frequency of ACA was significantly (P<0.001) higher in patients (32.0%) than in controls (7.1%). Only four patients (3.8%) were positive for both IgG and IgM ACA. The frequency of positive tests for ANA was also significantly (P<0.001) higher in patients (13.6%) than in controls (1.2%). No difference was found between first and second trimester aborters in the frequency of positive tests for either ACA or ANA. Primary aborters did not differ from secondary aborters in the frequency of ACA. However, secondary aborters had significantly higher frequency of ANA. There was no concordance between ACA and ANAN positive tests. These results suggest that ACA may be associated with some cases of unexplained recurrent abortions and that tests for both IgG and IgM isotypes should be carried out in the investigations of these patients.

Antibodies to phospholipids and nuclear antigens in non-pregnant women with unexplained spontaneous recurrent abortions

In a collaborative study of 73 non-pregnant Kuwaiti women with unexplained spontaneous recurrent abortion (RSA), 30 control healthy non-pregnant multiparous Kuwaiti women and 20 North American women who received elective abortion(s), autoantibodies to 6 phospholipids and 9 nuclear antigens were measured. Women with recurrent spontaneous abortions demonstrated 3 times higher incidence of antibodies to phospholipids (30.1%) than controls (10% each) (P = 0.029). The incidence of both IgM and IgA class antiphospholipid antibodies were significantly higher than those of controls. The incidence of antibodies to cardiolipin in women with recurrent spontaneous abortions (12.3%) was significantly higher than those of controls (P = 0.035) and incidence of IgM but not IgG anticardiolipin antibody was significantly higher in women with RSAs than in controls (P = 0.053). The incidences of anti-polyinosinic acid (P = 0.035) and anti-histone 1 antibody (P = 0.052) were significantly higher in women with recurrent spontaneous abortions than controls. There was no significant difference in the incidence of autoantibodies between primary and secondary aborters. However, women with a history of second trimester abortions showed a higher incidence of antiphospholipid antibodies than women with first trimester abortions only. Recurrent spontaneous abortion is associated with autoantibodies to phospholipid epitopes including IgA antiphospholipid antibodies.

Paternal leukocyte immunization in primary recurrent spontaneous aborters

This was a pilot study to investigate the possible roles of human lymphocyte antigen (HLA), antipeternal lymphocytotoxic antibodies, and maternal antipaternal mixed lymphocyte reaction (MLR) blocking antibodies in the maintenance of pregnancy following paternal leukocyte immunization for patients with recurrent abortions. A total of 36 patients with unexplained, first trimester, primary recurrent spontenous abortions were investigated for the detection of these two antibodies. There was a 43.3% rate of discordance in the presence of the two antibodies (P <0.05). A total of 26 of these women who lacked either antibody were immunized with paternal leukocyctes on two occasions and the assays were repeated post-immunization. The seroconversion rate was 50% for lymphocytotoxic antibodies and 61.5% for maternal serum (MLR) blocking antibodies. Twenty patients achieved pregnancies post-immunization, 11 completed their pregnancies successfully, and 9 re-aborted. A total of 83.3% of patients who developed MLR blocking antibodies post-immunization had successful pregnancies while those who failed to seroconvert aborted again. This difference is statistically significant (P<.05). A total of 50% of patients who developed lymphocytotoxic antibodies post-immunization had successful pregnancies while only 40% who failed to seroconvert re-aborted. This difference, we felt, was not statistically significant. The development of MLR blocking antibodies psot-immunization is a better indicator of subsequent successful pregnancies than lymphocytotoxic antibodies.

Hydatidiform mole in the elderly: hysterectomy or evacuation?

Ten patients with hydatidiform mole treated by primary hysterectomy were retrospectively compared with 24 patients whose moles were evacuated by suction curettage. All patients were 35 years old or more and were followed up for 1 year following the evacuation. During follow-up, 10% of the hysterectomized patients needed chemotherapy in comparison with 33.4% of the non-hysterectomized patients. This difference was not statistically significant. There was also no statistically significant difference when the serial serum beta-subunit of human chorionic gonadotrophin (beta-hCG) regression rates of the two groups were compared. The study shows that primary hysterectomy does not worsen the prognosis of gestational trophoblastic disease, however, it does not negate the need for careful follow-up.

Fertility with deletion Xq25: report of three cases; possible exceptions for critical region hypothesis

We report on an Arab family in which a mother and two of her daughters, despite having deletion Xq25, are fertile. So far, only one case of deletion Xq25 associated with fertility has been reported. Consistent inactivation of the deleted X chromosome in the proposita and early menopause in the mother were noted. The effect of Xq deletion on fertility and the CRH is discussed.

The effect of a copper intra-uterine contraceptive device on the microbial ecology of the female genital tract

Bacteria isolated from 108 intra-uterine contraceptive devices (IUCD) removed from patients with pelvic inflammatory disease (PID), haemorrhage, pregnancy and from asymptomatic women, and from the genital tracts of 66 healthy controls not wearing an IUCD, were studied. No significant differences were found in the types of micro-organisms or isolation rates from IUCDs removed from women in the various clinical groups. The isolation rate of anaerobic bacteria from IUCDs removed from asymptomatic wearers was significantly lower than that from controls, with the exception of the isolation rate of actinomyces which was significantly higher in IUCD wearers and A. israelii was recovered only from IUCDs. The isolation rates of the different bacterial species varied with the duration of the device in utero. The presence of a copper IUCD altered the bacterial flora of the female genital tract. The insertion of such a device and the ecological changes that follow play a crucial role in the development of PID.

Difficulties in the serodiagnosis of infection with the fragilis group of Bacteroides

Bacteroides antibodies were studied in sera from 74 patients infected with the fragilis group of Bacteroides and 74 healthy control persons, by immunofluorescence of 26 different serotypes of the fragilis group. Antibodies were present at titres of 10-320 in 65 (88%) patients and 50 (68%) controls (p less than 0.01). Titres of greater than or equal to 80 were demonstrated in sera of 38 (51%) patients and 5 (7%) controls (p less than 0.01). Specific IgM antibodies were detected in sera of 42 (57%) patients at a geometric mean titre (GMT) of 30, and 8 (11%) controls at a GMT of 11 (p less than 0.01). High antibody titres as well as specific IgM were found in 32 (43%) patients, while none of the controls showed such a combination (p less than 0.01). The majority of positive patients' sera (57%) reacted with five or more serotypes, whereas most positive control sera (51%) reacted against only one or two serotypes (p less than 0.01). A selected combination of serotypes not reacting with the control sera showed positive reactions with 52 (70%) patients' sera. These findings may be useful in devising schemes for the serodiagnosis of infection caused by the fragilis group of Bacteroides. However, there are indications of geographic variation in prevalence of serotypes, which may prevent the development of a single universal scheme.