Factors for Late Initiation of Antenatal Care in Kahama Municipal, Tanzania

Background: Maternal mortality is a major public health issue in developing countries due to its shocking magnitude and lower declining pattern, 295 000 women died of pregnancy or childbirth related complications in 2017. Late initiation of Antenatal Care (ANC) services in most low-income countries like Tanzania has been reported as a major problem which increase maternal mortality rate (MMR). However, different factors for late initiation of antenatal care are not well identified. Therefore, this study aimed to identify factors for late initiation of antenatal care both individual factors and health policy factors as per pregnant women and health care providers opinions in Kahama Municipal, Tanzania. Broad Objective: The study focused on assessment of factors for late initiation of Antenatal Care (ANC) in Kahama Municipal, Tanzania. Materials and Methods: This study was conducted using a qualitative method with exploratory approach which was carried out to explore factors for late initiation of antenatal care in Kahama Municipal. An in-depth interview (IDI) and Focus Group Discussion (FGD) were methods used to collect data. The study comprised of 14 in-depth interviews (IDIs) with pregnant women with age range of 18 years to 49 years attending antenatal care clinics in two health facilities and 4 in-depth interviews (IDIs) with health care providers attending pregnant women during antenatal care clinic visit. Furthermore, two Focus Group Discussions (FGDs), one from each health facility with pregnant women were conducted. Data Analysis: Thematic analysis was conducted through use of inductive approach. The audio recordings were conducted using the Swahili language then transcribed and translated into the English language where themes were obtained after translation. Results: Findings obtained from this study were factors for late initiation of antenatal care as reported by both pregnant women and health care providers. Factors for late initiation of antenatal care were under guidance of Health Behavioral Modal (HBM): Factors mentioned by pregnant women included pregnant women education level, negligence of pregnant women to attend clinic, unplanned pregnancy among couples, distance from pregnant women settlement to the facility, pregnant women misconceptions related to antenatal care services, use of local herbs, pregnancy complications, , unfriendly services and unequal gender power relation within a family. Factors mentioned by health care providers based on health policy and managerial factors such as Partner accompanying policy, distant allocation of health facility from people’s settlement and unfriendly services provided by health care providers. Conclusion: This study focused on assessing factors for late initiation of antenatal care in Kahama municipal council in Shinyanga, Tanzania. Different factors for late initiation of antenatal care were reported which included pregnant women and health care providers. Pregnant women education level, negligence of pregnant women to attend clinic, unplanned pregnancy among couples, and distance from pregnant women settlement to the facility, pregnant women misconceptions related to antenatal care services, use of local herbs, pregnancy complications. Health policy and managerial related factors were partner accompanying policy, unfriendly services, and allocation of health facility. Recommendation: However different improvement made on maternal health services in Tanzania but still some of pregnant women are not utilizing it efficiently because of different obstacles like distance from people’s settlement to the health facility, Partner accompanying policy and unfriendly services provided by health care providers. Through such obstacles as a policy maker, I would like to advice Government through Ministry of Health to allocate health facility nearby people’s settlement, providing outreach program to educate the community about antenatal care rather than relying on partner accompanying policy and lastly is provision of refresher training related to client’s rights during health care services provision to all staff.

Feeding in neonates with antenatal doppler abnormalities- a systematic review and meta-analysis

Preterm neonates with antenatal doppler abnormalities are at increased risk of necrotizing enterocolitis (NEC). In these neonates, we did a meta-analysis to compare the impact of early versus late initiation of feeding, and slow versus rapid feed advancement on the important neonatal outcomes. The databases of PubMed, Embase, Cochrane central, CINAHL and google scholar were searched on 6th September 2020. We included all randomized controlled trials addressing the study objective(s). The risk of bias was assessed using the Risk of Bias tool, version 2. Certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Early feeding did not increase the incidence of NEC stage 2 or more (odds ratio/OR 1.27, 95% confidence interval/CI 0.83, 1.96; 6 studies, 772 participants) and mortality (OR 0.79, 95% CI 0.4, 1.57; 3 studies, 498 participants). A trend was noted towards an increased incidence of feeding intolerance (OR 1.37, 95% CI 0.98, 1.92). There was a significant reduction in time to reach full feeds, duration of total parental nutrition, duration of hospital stay, and rates of hospital-acquired infections. The time to regain birth weight was not different. Rapid feed advancement decreased the time to reach full feeds, without affecting other outcomes. The overall certainty of the evidence was rated low. Heterogeneity was not significant. Conclusion: There is low-certainty evidence to recommend early feed initiation in preterm neonates with antenatal doppler abnormalities. The data is insufficient to make a recommendation on the rapidity of feed advancement.

Interim-analysis of the COSA (COVID-19 patients treated with the Seraph® 100 Microbind® Affinity filter) registry

Background The Seraph®100 Microbind Affinity Blood Filter® is a hemoperfusion device that is licensed for the reduction of pathogens, including several viruses, in the blood. It received Emergency Use Authorization (EUA) for the treatment of severe coronavirus disease 2019 (COVID-19) by the FDA. Several studies have shown that the blood viral load of SARS-CoV-2 correlates with adverse outcomes and removal of the nucleocapsid of the SARS-CoV-2 virus by the Seraph®100 has been recently demonstrated. The aim of this registry was to evaluate safety and efficacy of Seraph®100 treatment for COVID-19 patients. Methods Twelve hospitals from six countries representing two continents documented patient and treatment characteristics as well as outcome parameters without reimbursement. Additionally, mortality and safety results of the device were reported. One hundred-and-two treatment sessions in 82 patients were documented in the registry. Four patients were excluded from mortality analysis due to incomplete outcome data, which were available in the other 78 patients. Results Overall, a 30-day mortality rate of 46.2% in the 78 patients with complete follow up was reported. Median treatment time was 5.00 [4.00–13.42] h. and 43.1% of the treatments were performed as hemoperfusion only. Adverse events of the Seraph®100 treatment were reported in 8.8% of the 102 treatments and represented premature end of treatment due to circuit failure. Patients that died were treated later in their ICU stay and onset of COVID symptoms. They also had higher ferritin levels. Multivariate Cox regression revealed that delayed Seraph®100 treatment after ICU admission (>60 hours) as well as bacterial superinfection were associated with mortality. While average predicted mortality rate according to SOFA score in ICU patients was 56.7% the observed mortality was 50.7%. In non-ICU patients 4C-Score average predicted a mortality rate of 38.0% while the observed mortality rate was 11.1% Conclusions The treatment of COVID-19 patients with Seraph®100 is well tolerated and the circuit failure rate was lower than previously reported for KRT in COVID-19 patients. Mortality corelated with late initiation of Seraph treatment after ICU admission and bacterial superinfection infection. Compared to predicted mortality according to 4C-Score and SOFA Score, mortality of Seraph®100 treated patients reported in the registry was lower.

A Clinical Case of Extensive Drug Resistant Pulmonary Tuberculosis Using an Endobronchial Valve. Analysis of Errors in the Choice of Chemotherapy Regimen

The article describes a clinical case of a female patient with respiratory tuberculosis exposed to several cases of extensive drug resistance in their family. Tuberculosis progressed in this patient due to the late initiation of adequate treatment. Therefore, the total duration of chemotherapy made 5 years till cure was achieved and an endobronchial valve was used to heal persisting (for 3 years) lung destruction.

The Cost Effectiveness of Delaying Filgrastim Administration after Autologous Stem Cell Transplant in Patients with Multiple Myeloma - a Single Institution Experience

Background ASCO clinical guidelines recommends administration of WBC growth factors after autologous stem cell transplant (ASCT) to reduce the duration of severe neutropenia (Smith TJ et al., Recommendations for the use of WBC growth factors: American society of clinical oncology clinical practice guideline update. J Clin Oncol, 33(28):3199-3212, 2015). But there is conflicting data regarding the optimal timing of granulocyte colony stimulating factor (G-CSF) initiation post-transplantation and a lack of recent cost effectiveness analysis. Based on single center studies showing similar results between an early approach and a delayed one, we changed our institutional standard to a delayed strategy since June 2020. Methods We retrospectively compared the outcomes of adult multiple myeloma ASCT patients who received G-CSF either on day 2 (early) or day 5 (late) at Roger Williams Medical Center. Sixteen consecutive patients received day 2 G-CSF between July 2018 and June 2020 (D+2 cohort) while seven received day 5 since implementing the change in June 2020 (D+5 cohort). The doses of G-CSF given were 300 mcg, 480 mcg, 600 mcg or 960 mcg. One-way factorial ANOVA and Fit Y by X was used for comparison of variables. Descriptive statistics were used where appropriate. Results Baseline characteristics were comparable between the D+2 and D+5 cohorts (median age 62 vs 63 years, median CD34+cells 4.01 vs 4.54 x10 6/kg respectively). The median number of prior treatments, conditioning intensity, disease status at transplant and G-CSF doses were similar in both cohorts. Median ANC at G-CSF initiation was different (3300 in D+2 vs 100 in D+5). The median follow-up for survivors was 215 days for D+5 cohort (range: 135-404 days) and 699 days for D+2 cohort (range: 418-923 days). The results are summarized in table 1. For the primary outcome, median time to neutrophil engraftment was 13 days versus 10 days in the early and late cohorts, respectively (p=0.07). Median days from administration of GCSF to hospital discharge was noted to be shorter in the late cohort (13 vs 17.5 days, p=0.05). There was no statistically significant difference in the incidence of febrile neutropenia or transfusion requirements with late initiation of G-CSF. While engraftment syndrome and duration of antibiotics were noted to be more in the early cohort, these were not statistically significant. Median length of hospital stay was a day and half shorter in the late cohort. 6-month OS favored the D+5 cohort (p=0.03); this was likely due to transplant related deaths in early cohort. The average cost saving per patient by implementing the late strategy was 887.4 $. Conclusions Late initiation of G-CSF following autologous ASCT in patients with multiple myeloma was associated with a shorter time to neutrophil engraftment and length of stay post transplantation with no difference in overall outcomes. Cost benefit analysis favors delaying initiation of GCSF for autologous SCT at our center. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Differences in RNA polymerase II complexes and their interactions with surrounding chromatin on human and cytomegalovirus genomes

Interactions of the RNA polymerase II (Pol II) preinitiation complex (PIC) and paused early elongation complexes with the first downstream (+1) nucleosome are thought to be functionally important. However, current methods are limited for investigating these relationships, both for cellular chromatin and the human cytomegalovirus (HCMV) genome. Digestion with human DNA fragmentation factor (DFF) before immunoprecipitation (DFF-ChIP) precisely revealed both similarities and major differences in PICs driven by TBP on the host genome in comparison with PICs driven by TBP or the viral-specific, late initiation factor UL87 on the viral genome. Host PICs and paused Pol II complexes are frequently found in contact with the +1 nucleosome and paused Pol II can also be found in a complex involved in the initial invasion of the +1 nucleosome. In contrast, viral transcription complexes have very limited nucleosomal interactions, reflecting a relative lack of chromatinization of transcriptionally active regions of HCMV genomes.

Familial homozygous hypercholesterolemia in children: early diagnosis and treatment

Familial homozygous hypercholesterolemia is a rare life-threatening disease, the prevalence is 1: 160,000-1: 320,000. The main manifestation of the disease is an extremely high level of low-density lipoprotein cholesterol (more than 13 mmol / l), which causes early atherosclerotic vascular lesions, including coronary arteries, starting from the first decade of life, and can lead to myocardial infarction in childhood. Familial homozygous hypercholesterolemia remains a little-known disease in the clinical practice of the pediatrician; it leads to delayed diagnosis and late initiation of therapy. The most common cause of the disease is mutations in the LDLR (90%) gene, less often in the APOB (5–10%), PCSK9 (1%), LDLRAP1 (1%) genes. The article presents the criteria for the diagnosis of familial homozygous hypercholesterolemia in children. The authors discuss clinical manifestations on the skin and at the level of the cardiovascular system, eyes. They present the strategy of management and the possibilities of treating patients. The paper presents the indications for the appointment and the effectiveness of statins, ezetrol, monoclonal antibodies to PCSK9, apheresis for the treatment of the disease. It discusses prospects for further therapy.

The timing for initiating estrogen stimulation in artificial cycle for frozen-thawed embryo transfer can be flexible

Background There remains a lack of evidence to demonstrate whether the initiation time of estrogen stimulation is flexible in the proliferative endometrial phase during the artificial cycle for frozen-thawed embryo transfer (AC-FET). Methods FET records were retrospectively reviewed from a large university-affiliated reproductive medicine center. Only the patients who were undergoing their first embryo transfer with a single blastocyst in the AC-FET cycles were included: thereby 660 cycles were recruited, and the patients were grouped according to their day of estrogen usage initiation as early initiation group (estrogen stimulation initiated during days 2–5 of menses, n = 128) and the late initiation group (estrogen stimulation initiated on or after the 6th day of menses, n = 532). The primary outcome was the ongoing pregnancy rates (OPR). Results The rates of biochemical and clinical pregnancies were significantly higher in the late initiation group relative to those in the early initiation group, however, no significant differences were noted between the two groups for OPR. Furthermore, after adjusting for the results of the potential confounders, no impact was observed in the initiation time of estrogen stimulation on the OPR. Conclusions This study provides evidence that initiating the estrogen stimulation on after days 2–5 of menses do not exert adverse effects on the OPR in AC-FETs. Thus, AC-FET can be scheduled in a flexible manner without compromising on the pregnancy outcomes.