The Pathway to Improved Maternal and Newborn Health Outcomes: Use of data for maternal and newborn health in Gombe State, Nigeria

This leaflet describes the process of mapping innovations of projects funded by the Bill & Melinda Gates Foundation, which contribute to Gombe State maternal and newborn health provision. The process was discussed and agreed at a meeting in Abuja in January 2016 and this leaflet represents their work at that time. Participants at the meeting were from the Gombe State Primary Health Care Development Agency, Bill & Melinda Gates Foundation grantees operating in the State: the Society for Family Health, Pact’s SAQIP project, Champions for Change, MamaYe and IDEA

Did the strategy of skilled attendance at birth reach the poor in Indonesia?

Objective To assess whether the strategy of “a midwife in every village” in Indonesia achieved its aim of increasing professional delivery care for the poorest women. Methods Using pooled Demographic and Health Surveys (DHS) data from 1986–2002, we examined trends in the percentage of births attended by a health professional and deliveries via caesarean section. We tested for effects of the economic crisis of 1997, which had a negative impact on Indonesia’s health system. We used logistic regression, allowing for time-trend interactions with wealth quintile and urban/rural residence. Findings There was no change in rates of professional attendance or caesarean section before the programme’s full implementation (1986–1991). After 1991, the greatest increases in professional attendance occurred among the poorest two quintiles – 11% per year compared with 6% per year for women in the middle quintile ( P = 0.02). These patterns persisted after the economic crisis had ended. In contrast, most of the increase in rates of caesarean section occurred among women in the wealthiest quintile. Rates of caesarean deliveries remained at less than 1% for the poorest two-fifths of the population, but rose to 10% for the wealthiest fifth. Conclusion The Indonesian village midwife programme dramatically reduced socioeconomic inequalities in professional attendance at birth, but the gap in access to potentially life-saving emergency obstetric care widened. This underscores the importance of understanding the barriers to accessing emergency obstetric care and of the ways to overcome them, especially among the poor

Qualitative evidence syntheses : assessing the relative contributions of multi‐context and single‐context reviews

Aims To examine the strengths and weaknesses of multi‐context (international) qualitative evidence syntheses in comparison with single‐context (typically single‐country) reviews. We compare a multi‐country synthesis with single‐context syntheses on facility‐based delivery in Nigeria and Kenya. Design Discussion Paper. Background Qualitative evidence increasingly contributes to decision‐making. International organisations commission multi‐context reviews of qualitative evidence to gain a comprehensive picture of similarities and differences across comparable (e.g. low‐ and middle‐income) countries. Such syntheses privilege breadth over contextual detail, risking inappropriate interpretation and application of review findings. Decision‐makers value single‐context syntheses that account for the contexts of their populations and health services. We explore how findings from multi‐ and single‐context syntheses contribute against a conceptual framework (adequacy, coherence, methodological limitations and relevance) that underpins the GRADE Confidence in Evidence of Reviews of Qualitative Evidence approach. Data sources Included studies and findings from a multi‐context qualitative evidence synthesis (2001‐2013) and two single‐context syntheses (Nigeria, 2006‐2017; and Kenya, 2002‐2016; subsequently, updated and revised). Findings Single‐context reviews contribute cultural, ethnic and religious nuances as well as specific health system factors (e.g. use of a voucher system). Multi‐context reviews contribute to universal health concerns and to generic health system concerns (e.g. access and availability). Implications for nursing: Nurse decision‐makers require relevant, timely and context‐sensitive evidence to inform clinical and managerial decision‐making. This discussion paper informs future commissioning and use of multi‐ and single‐context qualitative evidence syntheses. Conclusion Multi‐ and single‐context syntheses fulfil complementary functions. Single‐context syntheses add nuances not identifiable within the remit and timescales of a multi‐context review

Elevated Plasma Homocysteine Level as a Risk Factor for Hypertension

Wstęp Celem pracy była ocena związku pomiędzy stężeniem homocysteiny a występowaniem nadciśnienia tętniczego. Materiał i metody W badaniu uczestniczyło 88 pacjentów z nadciśnieniem tętniczym (62 mężczyzn i 26 kobiet, w wieku 18-72 lat) i 120 zdrowych ochotników (87 mężczyzn i 33 kobiety, w wieku 32-81 lat). Stężenie homocysteiny w osoczu oznaczono metodą FPI (Fluorescence Polarization Immunoassay), stężenie kwasu foliowego i witaminy B12 oznaczono metodą chemiluminescencji. Wyniki Stężenie homocysteiny było większe w grupie pacjentów niż w grupie kontrolnej (12,07 &plusmn; 5,1 vs. 10,72 &plusmn; 2,13 mmol/l, p < 0,001, skorygowane względem wieku). Podwyższone stężenie homocysteiny - definiowane jako stężenie powyżej 90 percentyla rozkładu w grupie kontrolnej (ł 13,52 mmol/l) - zaobserwowano u 24% pacjentów i u 10% osób z grupy kontrolnej. Iloraz szans (OR, odds ratio) wystąpienia nadciśnienia tętniczego u osób z podwyższonym stężeniem homocysteiny wyniósł 2,8 (95-procentowy przedział ufności 1,3-6,1, p < 0,01). W analizie wieloczynnikowej, po uwzględnieniu innych czynników ryzyka (wiek, płeć, wskaźnik masy ciała, palenie tytoniu, występowanie chorób układu krążenia w rodzinie, hiperlipidemia), podwyższone stężenie homocysteiny pozostało niezależnym czynnikiem ryzyka nadciśnienia tętniczego (OR 6,6, 95-procentowy przedział ufności 2,3-19,1, p < 0,001). Iloraz szans wystąpienia nadciśnienia tętniczego przy wzroście stężenia homocysteiny o 5 mmol/l wyniósł 1,7 (95-procentowy przedział ufności 1,1-2,6, p < 0,001), a w analizie wieloczynnikowej 3,8 (95-procentowy przedział ufności 1,7&#8211;8,2, p < 0,001). Wnioski Podwyższone stężenie homocysteiny jest ważnym czynnikiem ryzyka nadciśnienia tętniczego. Wzrost stężenia homocysteiny o 5 mmol/l może wiązać się z co najmniej 2-krotnym wzrostem ryzyka nadciśnienia tętniczego.Background The aim of the study was to assess the significance of association between hypertension (Ht) and circulating homocysteine concentrations. Material and methods 88 consecutive hypertensive patients (62 men and 26 women, aged 18 to 72 years) and 120 healthy controls (87 men and 33 women, aged 32&#8211;81 years) were investigated. Homocysteine was assayed using Fluorescence Polarisation Immunoassay on the IMx Analyser made by Axis Biochemicals. Plasma folate and plasma vitamin B12 were assayed with chemiluminescency and IMMULITE Automated Analyser made by the Diagnostic Products Corporation. Results Homocysteine concentrations were higher in patients than in controls (12,07 &plusmn; 5,1 vs. 10,72 &plusmn; 13 mmol/L, p < 0,001, adjusted for age). Elevated homocysteine level - defined as a level above the 90th percentile of the control distribution (ł 13,52 mmol/L) - was seen in 24% of the patients compared with 10% of the control group (p < 0,05). The odds ratio (OR) for Ht in persons with an elevated homocysteine level was 2,8 (95% CI 1,3-6,1, p < 0,01). After adjustment for conventional risk factors (age, gender, body mass index, smoking, family history of cardiovascular disease, hyperlipidemia), an elevated homocysteine level remained an independent risk factor for Ht (OR 6,6, 95% CI 2,3-19,1, p < 0,001). The OR for Ht of 5 mmol/L increment in homocysteine level was 1,7 (95% CI 1,1-2,6, p < 0,001), and in multivariate analysis OR was 3,8 (95% CI 1,7-8,2, p < 0,001). Conclusion An elevated plasma homocysteine level is a strong risk factor for hypertension. A 5 mmol/L increment in total homocysteine level may be associated with at least a twofold increase of risk for hypertension

Adrenomedullin in Hypertension and Other Diseases of Cardiovascular System

Adrenomedullina (ADM) jest białkiem składającym się z 52 aminokwasów, odkrytym przez Kitamurę i wsp. w 1993 r. w komórkach guza chromochłonnego nadnerczy. Wykazuje podobieństwo do peptydu związanego z genem kalcytoniny - CGRP (calcitonine gene related peptide) - oraz do amyliny, posiadających strukturę pierścieniową i resztę amidową na końcu karboksylowym. Największą ekspresję stwierdzono w komórkach śródbłonka i mięśni gładkich naczyń. Wykazano, że w warunkach fizjologicznych stężenie ADM w osoczu u ludzi mieści się w szerokim zakresie 1-10 pmol/l i w większości badań nie przekracza wartości 2-3,5 pmol/l. Dzięki badaniom eksperymentalnym oraz klinicznym poznano wiele czynników wpływających na syntezę i sekrecję ADM. Działając na komórki mięśni gładkich, ADM powoduje gromadzenie w nich cAMP. Badania wykazują, że efekty biologiczne wywierane przez ADM mogą również zależeć od tlenku azotu (NO). Najlepiej poznanym receptorem dla ADM jest receptor o budowie podobnej do receptora kalcytoniny - CRLR (calcitonin receptor like receptor). Adrenomedullina wywiera silne i długotrwałe działanie hipotensyjne oraz wywołuje silny efekt diuretyczny i natriuretyczny. W warunkach patologicznych stężenie adrenomedulliny jest podwyższone po zawale i w niewydolności serca, w chorobach nerek, nadciśnieniu pierwotnym oraz u chorych z pierwotnym hiperaldosteronizmem.Adrenomedullin was originally isolated from pheochromocytoma cells, but it is also produced and secreted by cardiovascular system, including heart, lung, aorta, vascular smooth muscle cells and endothelial cells. It is a potent vasodilator peptide consisting of 52 amino acids and it belongs to the calcitonin gene-related peptide (CGRP) superfamily. ADM receptors have always been closely associated with receptors for the related peptide CGRP, but there are receptors with higher affinity for ADM than CGRP. ADM have been shown to elevate cAMP levels in various tissue and cells. Moreover, it has also been shown that ADM dilates regional vascular bed not only in cAMP-dependent mechanism but also an NO/cGMP mechanism may be involved in. Plasma ADM levels are typically in the lower picomolar range in normal humans, and there are many factors that increase its levels. The role of ADM in the cardiovascular and endocrine regulation hasn&#8217;t been fully elucidated yet. It is clear, however, that exogenous ADM has powerful vasodilator and natriuretic actions. ADM levels are increased in patients with hypertension, renal disease and heart failure in proportion to the clinical severity of these disorders. Moreover, it has been reported that ADM may play a role in the pathogenesis of essential and secondary hypertension characterized by excessive catecholamine and aldosterone secretion