Routine antenatal ultrasound in low- and middle-income countries: first look - a cluster randomised trial

OBJECTIVE

Ultrasound is widely regarded as an important adjunct to antenatal care (ANC) to guide practice and reduce perinatal mortality. We assessed the impact of ANC ultrasound use at health centres in resource-limited countries.

DESIGN

Cluster randomised trial.

SETTING

Clusters within five countries (Democratic Republic of Congo, Guatemala, Kenya, Pakistan, and Zambia) METHODS: Clusters were randomised to standard ANC or standard care plus two ultrasounds and referral for complications. The study trained providers in intervention clusters to perform basic obstetric ultrasounds.

MAIN OUTCOME MEASURES

The primary outcome was a composite of maternal mortality, maternal near-miss mortality, stillbirth, and neonatal mortality.

RESULTS

During the 24-month trial, 28 intervention and 28 control clusters had 24 263 and 23 160 births, respectively; 78% in the intervention clusters received at least one study ultrasound; 60% received two. The prevalence of conditions noted including twins, placenta previa, and abnormal lie was within expected ranges. 9% were referred for an ultrasound-diagnosed condition, and 71% attended the referral. The ANC (RR 1.0 95% CI 1.00, 1.01) and hospital delivery rates for complicated pregnancies (RR 1.03 95% CI 0.89, 1.20) did not differ between intervention and control clusters nor did the composite outcome (RR 1.09 95% CI 0.97, 1.23) or its individual components.

CONCLUSIONS

Despite availability of ultrasound at ANC in the intervention clusters, neither ANC nor hospital delivery for complicated pregnancies increased. The composite outcome and the individual components were not reduced.

TWEETABLE ABSTRACT

Antenatal care ultrasound did not improve a composite outcome that included maternal, fetal, and neonatal mortality.

The increasing cost of the basic foods required to promote health in Queensland

OBJECTIVE

To assess changes in the cost and availability of a standard basket of healthy food items (the Healthy Food Access Basket [HFAB]) in Queensland over time.

DESIGN AND PARTICIPANTS

A series of four cross-sectional surveys (in 1998, 2000, 2001 and 2004) describing the cost and availability of foods in the HFAB over time. In the latest survey, 97 Queensland food stores across the five Australian Bureau of Statistics remoteness categories were compared.

MAIN OUTCOME MEASURES

Cost comparisons for HFAB items by remoteness category for the 97 stores surveyed in 2004; changes in cost and availability of foods in the 81 stores surveyed since 2000; comparisons of food prices in the 56 stores surveyed in 1998, 2000, 2001 and 2004.

RESULTS

In 2004, the Queensland mean cost of the HFAB was $395.28 a fortnight. The cost of the HFAB was 29.6% ($113.89) higher in "very remote" areas than in "major cities" (P < 0.001). Between 2001 and 2004, the Queensland mean cost of the HFAB increased by 14.0% ($48.45), while in very remote areas the cost increased by 18.0% ($76.93) (P < 0.001). Since 2000, the annualised per cent increase in cost of the HFAB has been higher than the increase in Consumer Price Index for food in Brisbane. The cost of healthy foods has risen more than the cost of some less nutritious foods, so that the latter are now relatively more affordable.

CONCLUSIONS

Consumers, particularly those in very remote locations, need to pay substantially more for basic healthy foods than they did a few years ago. Higher prices are likely to be a barrier to good health among people of low socioeconomic status and other vulnerable groups. Interventions to make basic healthy food affordable and accessible to all would help reduce the high burden of chronic disease.

Chloroplast Oxa1p homolog albino3 is required for post-translational integration of the light harvesting chlorophyll-binding protein into thylakoid membranes

Multiple sorting pathways operate in chloroplasts to localize proteins to the thylakoid membrane. The signal recognition particle (SRP) pathway in chloroplasts employs the function of a signal recognition particle (cpSRP) to target light harvesting chlorophyll-binding protein (LHCP) to the thylakoid membrane. In assays that reconstitute stroma-dependent LHCP integration in vitro, the stroma is replaceable by the addition of GTP, cpSRP, and an SRP receptor homolog, cpFtsY. Still lacking is an understanding of events that take place at the thylakoid membrane including the identification of membrane proteins that may function at the level of cpFtsY binding or LHCP integration. The identification of Oxa1p in mitochondria, an inner membrane translocase component homologous to predicted proteins in bacteria and to the albino3 (ALB3) protein in thylakoids, led us to investigate the potential role of ALB3 in LHCP integration. Antibody raised against a 50-amino acid region of ALB3 (ALB3-50aa) identified a single 45-kDa thylakoid protein. Treatment of thylakoids with antibody to ALB3-50aa inhibited LHCP integration, whereas the same antibody treatment performed in the presence of antigen reversed the inhibition. In contrast, transport by the thylakoid Sec or Delta pH pathways was unaffected. These data support a model whereby a distinct translocase containing ALB3 is used to integrate LHCP into thylakoid membranes.

Rotavirus: an overview--from discovery to vaccine

Rotavirus is the single most important cause of both nosocomially-acquired and severe, dehydrating diarrhea. It occurs with equal frequency throughout the world, regardless of the level of sanitation. After primary infection, mild or asymptomatic reinfection is common. Current management involves the use of oral rehydration therapy and early feeding of an age-appropriate diet. Cereal-based oral rehydration solutions, lactic acid bacteria, and oral immunoglobulins may play a role in future treatment. A rhesus rotavirus, quadravalent oral vaccine, currently being considered for licensure, may be given concurrently with other routine infant immunizations and has an efficacy rate of 80% against severe disease. Pediatric nurses should be aware of these recent advances in treatment and prevention, which should significantly reduce the impact of rotavirus in the near future.

Trimethoprim-induced aseptic meningitis in a patient with AIDS: case report and review

We report the case of a 41-year-old man infected with human immunodeficiency virus who had two episodes of aseptic meningitis that occurred 2 weeks apart; the first was associated with ingestion of trimethoprim-sulfamethoxazole (TMP-SMZ) and the second was associated with ingestion of TMP alone. Onset of fever, headache, and flushing was abrupt, followed by somnolence, hearing loss, and aphasia. Analysis of the CSF showed pleocytosis and an elevated protein level. The findings resolved within 48 hours after withdrawal of the drug. We also review 18 previously reported cases of TMP-SMZ- or TMP-induced meningitis, 17 of which occurred in women. In all of these cases, a similar abrupt onset and resolution were noted. Six of the 18 patients had collagen-vascular diseases. All but two of these patients had multiple recurrent episodes of meningitis before the diagnosis was made. We conclude that the diagnosis of TMP-SMZ- or TMP-induced meningitis should be considered when a patient receiving these drugs has recurrent episodes of aseptic meningitis.

The facial tics

The abnormal movements of the facial muscles are classified and the diagnosis and treatment considered in light of 22 cases of hemifacial spasm. Forms of treatment which give only temporary cessation of spasm and require complex and unpleasant treatment to be oft repeated are seldom tolerated for long by the patient. Permanent cure of spasm can only be obtained when the facial nerve or its branch to the muscle is permanently divided or the muscle itself excised. Neurotomy as practised by German (1942) and Scoville (1955) has not been found satisfactory in the present series. Neuro-anastomosis at different sites in the course of the 7th nerve is discussed and shown to be of value in patients with severe widespread spasm and in those in which the spasm is more localised. This method results in only temporary palsy of the facial muscles, the duration of the palsy depending on the site of the division of the facial nerve.

A comparison of methods of extra temporal facial nerve repair

The development during the past 100 years of methods of repair of the divided facial nerve is discussed, from the early attempts to bring the nerve ends together inside a tube of vein. The success of the repair is enhanced by the care of the blood supply to the nerve and by measures to avoid scar developing between the ends of the nerve. Rest of the suture line is aided by the support of some form of tube, but unless this latter is kept below I cm. in length interference with the radial blood vessels to the nerve occurs. Intubation also encourages parallel growth of the nerve fibres and discourages fibroblast proliferation. Animal experimentation shows that the results when a soft silicone tube of special shape is used are superior to those obtained if the nerve is left free in the tissues, buried in muscle, or placed inside a vein.

Positional vertigo

Different forms of positional nystagmus, particularly the continuous (type I) variety, were found in 86 consecutive patients admitted to general and neurological hospitals. This series is compared with 365 patients with paroxysmal (type II) and 23 patients with type III positional nystagmus. In this series of 32 of the patients with continuous type I positional nystagmus (including 15 patients with head injury) and 18 of the patients with paroxysmal type II nystagmus were found to have central lesions.

Note on the value of Frenzel's glasses for the recognition and qualitative evaluation of spontaneous nystagmus

Spontaneous nystagmus encountered in neuro-otological practice is nearly always a physical sign of high diagnostic importance. Its localizing value is largely determined by certain of its qualitative characteristics and these are best studied and evaluated by means of the electronystagmograph, but for reasons discussed this is not suitable for use in smaller clinics. For the recognition and qualitative analysis of spontaneous nystagmus the use of Frenzel's glasses used in complete darkness, as recommended by Frenzel himself, has been found to give very satisfactory results.