Independent and combined effects of improved water, sanitation, and hygiene, and improved complementary feeding, on child stunting and anaemia in rural Zimbabwe: a cluster-randomised trial.

BACKGROUND: Child stunting reduces survival and impairs neurodevelopment. We tested the independent and combined effects of improved water, sanitation, and hygiene (WASH), and improved infant and young child feeding (IYCF) on stunting and anaemia in in Zimbabwe. METHODS: We did a cluster-randomised, community-based, 2 × 2 factorial trial in two rural districts in Zimbabwe. Clusters were defined as the catchment area of between one and four village health workers employed by the Zimbabwe Ministry of Health and Child Care. Women were eligible for inclusion if they permanently lived in clusters and were confirmed pregnant. Clusters were randomly assigned (1:1:1:1) to standard of care (52 clusters), IYCF (20 g of a small-quantity lipid-based nutrient supplement per day from age 6 to 18 months plus complementary feeding counselling; 53 clusters), WASH (construction of a ventilated improved pit latrine, provision of two handwashing stations, liquid soap, chlorine, and play space plus hygiene counselling; 53 clusters), or IYCF plus WASH (53 clusters). A constrained randomisation technique was used to achieve balance across the groups for 14 variables related to geography, demography, water access, and community-level sanitation coverage. Masking of participants and fieldworkers was not possible. The primary outcomes were infant length-for-age Z score and haemoglobin concentrations at 18 months of age among children born to mothers who were HIV negative during pregnancy. These outcomes were analysed in the intention-to-treat population. We estimated the effects of the interventions by comparing the two IYCF groups with the two non-IYCF groups and the two WASH groups with the two non-WASH groups, except for outcomes that had an important statistical interaction between the interventions. This trial is registered with ClinicalTrials.gov, number NCT01824940. FINDINGS: Between Nov 22, 2012, and March 27, 2015, 5280 pregnant women were enrolled from 211 clusters. 3686 children born to HIV-negative mothers were assessed at age 18 months (884 in the standard of care group from 52 clusters, 893 in the IYCF group from 53 clusters, 918 in the WASH group from 53 clusters, and 991 in the IYCF plus WASH group from 51 clusters). In the IYCF intervention groups, the mean length-for-age Z score was 0·16 (95% CI 0·08-0·23) higher and the mean haemoglobin concentration was 2·03 g/L (1·28-2·79) higher than those in the non-IYCF intervention groups. The IYCF intervention reduced the number of stunted children from 620 (35%) of 1792 to 514 (27%) of 1879, and the number of children with anaemia from 245 (13·9%) of 1759 to 193 (10·5%) of 1845. The WASH intervention had no effect on either primary outcome. Neither intervention reduced the prevalence of diarrhoea at 12 or 18 months. No trial-related serious adverse events, and only three trial-related adverse events, were reported. INTERPRETATION: Household-level elementary WASH interventions implemented in rural areas in low-income countries are unlikely to reduce stunting or anaemia and might not reduce diarrhoea. Implementation of these WASH interventions in combination with IYCF interventions is unlikely to reduce stunting or anaemia more than implementation of IYCF alone. FUNDING: Bill & Melinda Gates Foundation, UK Department for International Development, Wellcome Trust, Swiss Development Cooperation, UNICEF, and US National Institutes of Health.The SHINE trial is funded by the Bill & Melinda Gates Foundation (OPP1021542 and OPP113707); UK Department for International Development; Wellcome Trust, UK (093768/Z/10/Z, 108065/Z/15/Z and 203905/Z/16/Z); Swiss Agency for Development and Cooperation; US National Institutes of Health (2R01HD060338-06); and UNICEF (PCA-2017-0002)

Safety, feasibility, and efficacy of bilateral synchronous percutaneous nephrolithotomy for bilateral stone disease: Evidence from a systematic Review

INTRODUCTION: With the evolution of endourologic technology, bilateral synchronous percutaneous nephrolithotomy (BS-PCNL) has emerged as a potentially practical intervention for patients with bilateral lithiasis. Although tradition has favored a staged approach, an increasing number of original studies have reported their experiences with the synchronous approach.MATERIALS AND METHODS: A Cochrane style search was performed after development of a sensitive and predefined search strategy. Primary outcomes measured were initial and final stone-free rate (SFR), drop in hemoglobin, hospital stay, operative time, and complication rates. Additional information was collected on (but not limited to) baseline characteristics, stone complexity, number of tracts made, success rate, and transfusion rate.RESULTS: From a total 187 studies, 11 were identified (published between 1997 and 2015), and they were included in this review. In total, 594 patients with a mean age of 46 years and a male:female ratio of 3:1 underwent BS-PCNL procedures, the majority of which was under the prone position. In 87.1% (range: 71.4%-100%) of cases, the synchronous approach was performed as planned. Multiple access tracts were established in an average of 16.7% (4.1%-24%) renal units. Mean initial SFR and final SFR were 72.6% (49%-85%) and 92.4% (87%-96.9%), respectively, with a mean operative time of 171.1 minutes (range: 107.4-269 minutes). Mean hospital stay was 3.9 days (range: 1.25-15 days). Mean complication rate per study was 23.4% (range: 12.1%-54% per study). The majority were Clavien Grade 1 (60.9%), of which fever resolving spontaneously was the most common complication. No deaths were reported in any of the papers.CONCLUSION: BS-PCNL seems to be a good endourologic approach for patients with bilateral stone disease, which can render high SFRs and maintain a noninferior safety profile compared with the staged approach. This technique demands careful patient selection, counseling and should be preferably performed in endourology centers with large case volumes.</p