Children with severe malnutrition: can those at highest risk of death be identified with the WHO protocol?

Background With strict adherence to international recommended treatment guidelines, the case fatality for severe malnutrition ought to be less than 5%. In African hospitals, fatality rates of 20% are common and are often attributed to poor training and faulty case management. Improving outcome will depend upon the identification of those at greatest risk and targeting limited health resources. We retrospectively examined the major risk factors associated with early (<48 h) and late in-hospital death in children with severe malnutrition with the aim of identifying admission features that could distinguish a high-risk group in relation to the World Health Organization (WHO) guidelines. Methods and Findings Of 920 children in the study, 176 (19%) died, with 59 (33%) deaths occurring within 48 h of admission. Bacteraemia complicated 27% of all deaths: 52% died before 48 h despite 85% in vitro antibiotic susceptibility of cultured organisms. The sensitivity, specificity, and likelihood ratio of the WHO-recommended “danger signs” (lethargy, hypothermia, or hypoglycaemia) to predict early mortality was 52%, 84%, and 3.4% (95% confidence interval [CI] = 2.2 to 5.1), respectively. In addition, four bedside features were associated with early case fatality: bradycardia, capillary refill time greater than 2 s, weak pulse volume, and impaired consciousness level; the presence of two or more features was associated with an odds ratio of 9.6 (95% CI = 4.8 to 19) for early fatality (p < 0.0001). Conversely, the group of children without any of these seven features, or signs of dehydration, severe acidosis, or electrolyte derangements, had a low fatality (7%). Conclusions Formal assessment of these features as emergency signs to improve triage and to rationalize manpower resources toward the high-risk groups is required. In addition, basic clinical research is necessary to identify and test appropriate supportive treatments

Redesigning Public Speaking: A Case Study in the Use of Instructional Design to Create the Interchange Model

This case study describes the redesign of Public Speaking at a Research I institution. An instructional analysis revealed strengths of and concerns about the existing model--large lecture with small lab sections. Criteria for a new model emerged from that analysis, all of which hinged on an overarching goal: The course should incorporate learning theory and disciplinary theory and should result in student learning, student skill development, and enhanced satisfaction among stakeholders. The Interchange Model, which included some online delivery, was developed to meet identified needs and was fleshed out with course materials and semester plans. The model was piloted and then fully implemented with positive results

Equine atypical myopathy associated with sycamore seed ingestion in a Przewalski foal

One of the 172 UK cases of equine atypical myopathy (EAM) reported to the Atypical Myopathy Alert Group (AMAG) in 2014 was that of a five-month old male Przewalski horse (Equus ferus przewalskii), resident at ZSL Whipsnade Zoo, UK. The foal presented initially with sudden-onset and repeated stretching of the neck as if dysphagic, with progressive weakness (including lying down), sweating and an unresponsive demeanour. General anaesthesia, induced with a combination of etorphine, midazolam and hyaluronidase, was required for each examination and subsequent treatment of the foal. Initial biochemical analysis showed a markedly increased plasma creatine kinase (CK) activity of 105,001 U/L, an increased aspartate amino transferase (AST) activity of 4194 U/L and a mildly increased inorganic phosphorus concentration of 2.35 mmol/L. The foal was unresponsive to treatment and had to be euthanased. Skeletal musculature and the myocardium showed the most significant pathological changes, with histological evidence of rhabdomyolysis, whilst urine organic acid analysis and an abnormal organic acid serum profile were supportive of multiple acyl Co-A dehydrogenase deficiency typical of EAM. This is the first description of EAM in a non-domestic equid

The structure of Serratia marcescens Lip, a membrane-bound component of the type VI secretion system

The high-resolution crystal structure of S. marcescens Lip reveals a new member of the transthyretin family of proteins. Lip, a core component of the type VI secretion apparatus, is localized to the outer membrane and is positioned to interact with other proteins forming this complex system

High Latitude Radio Emission in a Sample of Edge-On Spiral Galaxies

We have mapped 16 edge-on galaxies at 20 cm using the VLA. For 5 galaxies, we could form spectral index, energy and magnetic field maps. We find that all but one galaxy show evidence for non-thermal high latitude radio continuum emission, suggesting that cosmic ray halos are common in star forming galaxies. The high latitude emission is seen over a variety of spatial scales and in discrete and/or smooth features. In general, the discrete features emanate from the disk, but estimates of CR diffusion lengths suggest that diffusion alone is insufficient to transport the particles to the high latitudes seen (> 15 kpc in one case). Thus CRs likely diffuse through low density regions and/or are assisted by other mechanisms (e.g. winds). We searched for correlations between the prevalence of high latitude radio emission and a number of other properties, including the global SFR, supernova input rate per unit star forming, and do not find clear correlations with any of these properties.Comment: 40 pages of text, 3 figures, 6 tables, and an appendix of 21 jpeg figures (which is a radio continuum catalogue of 17 galaxies). to appear in A. J. (around January 1999

Interstellar Turbulence: II. Energy Spectra of Molecular Regions in the Outer Galaxy

The multivariate tool of Principal Component Analysis (PCA) is applied to 23 fields in the FCRAO CO Survey of the Outer Galaxy. PCA enables the identification of line profile differences which are assumed to be generated from fluctuations within a turbulent velocity field. The variation of these velocity differences with spatial scale within a molecular region is described by a singular power law, delta v= c L^alpha which can be used as a powerful diagnostic to turbulent motions. For the ensemble of 23 fields, we find a mean value alpha = 0.62 +- 0.11. From a recent calibration of this method using fractal Brownian motion simulations (Brunt & Heyer 2001), the measured velocity difference-size relationship corresponds to an energy spectrum, E(k), which varies as k^-beta, where beta = 2.17 +- 0.31. We compare our results to both decaying and forced hydrodynamic simulations of turbulence. We conclude that energy must be continually injected into the regions to replenish that lost by dissipative processes such as shocks. The absence of large, widely distributed shocks within the targeted fields suggests that the energy is injected at spatial scales less than several pc.Comment: 24 pages, 10 figures, accepted by Ap

Red cell differential width (RDW) as a predictor of survival outcomes with palliative and adjuvant chemotherapy for metastatic penile cancer.

PURPOSE: Red cell distribution width (RDW) measures red cells' size variability. Metastatic penile cancer displays poor chemotherapy response. As no validated prognostic predictor exists, we investigated whether RDW correlates independently with survival outcomes in metastatic penile cancer treated by chemotherapy. METHODS: Electronic chemotherapy files of patients with metastatic penile cancer (M1 or N3) from a large academic supra-regional centre were retrospectively analysed between 2005 and 2018. Patients were stratified into RDW > 13.9% and < 13.9%, as per published data on RDW in renal cell carcinoma. Survival time was calculated from the date of chemotherapy initiation until the date of death. RESULTS: 58 patients were analysed. The RDW-high group (n = 31) had a poorer survival than the RDW-low group (n = 27). Median overall survival (mOS) in all patients was 19.0 months (95% CI 13.1-24.9). mOS for RDW-high was 15.0 months (95% CI 10.1-19.9) and 37.0 months (95% CI 32.3-43.1) for RDW-low. Kaplan-Meier curves showed a clear disparity in survival (log rank p = 0.025). Cox proportional hazard ratio for death, corrected for T-stage, grade, age and deprivation score was 0.43 (p = 0.04). Sub-analysis of the M1 patients showed mOS in RDW-high of 17 m (95% CI 11.6-22.4) vs. NR; HR for death of 0.42. N3 patients' mOS in RDW-high cohort was 30 months (95% CI 4.5-55.9) vs. 13 months (95% CI 1.8-24.2) in RDW-low; HR for death was 0.30. CONCLUSION: RDW correlates independently with survival outcomes in metastatic penile cancer and may act as a potential predictor of survival outcomes for patients with metastatic penile cancer receiving chemotherapy

Brucella abortus Infection of Placental Trophoblasts Triggers Endoplasmic Reticulum Stress-Mediated Cell Death and Fetal Loss via Type IV Secretion System-Dependent Activation of CHOP.

Subversion of endoplasmic reticulum (ER) function is a feature shared by multiple intracellular bacteria and viruses, and in many cases this disruption of cellular function activates pathways of the unfolded protein response (UPR). In the case of infection with Brucella abortus, the etiologic agent of brucellosis, the unfolded protein response in the infected placenta contributes to placentitis and abortion, leading to pathogen transmission. Here we show that B. abortus infection of pregnant mice led to death of infected placental trophoblasts in a manner that depended on the VirB type IV secretion system (T4SS) and its effector VceC. The trophoblast death program required the ER stress-induced transcription factor CHOP. While NOD1/NOD2 expression in macrophages contributed to ER stress-induced inflammation, these receptors did not play a role in trophoblast death. Both placentitis and abortion were independent of apoptosis-associated Speck-like protein containing a caspase activation and recruitment domain (ASC). These studies show that B. abortus uses its T4SS to induce cell-type-specific responses to ER stress in trophoblasts that trigger placental inflammation and abortion. Our results suggest further that in B. abortus the T4SS and its effectors are under selection as bacterial transmission factors.IMPORTANCE Brucella abortus infects the placenta of pregnant cows, where it replicates to high levels and triggers abortion of the calf. The aborted material is highly infectious and transmits infection to both cows and humans, but very little is known about how B. abortus causes abortion. By studying this infection in pregnant mice, we discovered that B. abortus kills trophoblasts, which are important cells for maintaining pregnancy. This killing required an injected bacterial protein (VceC) that triggered an endoplasmic reticulum (ER) stress response in the trophoblast. By inhibiting ER stress or infecting mice that lack CHOP, a protein induced by ER stress, we could prevent death of trophoblasts, reduce inflammation, and increase the viability of the pups. Our results suggest that B. abortus injects VceC into placental trophoblasts to promote its transmission by abortion

A Rapid Assessment of the Quality of Neonatal Healthcare in Kilimanjaro Region, Northeast Tanzania.

While child mortality is declining in Africa there has been no evidence of a comparable reduction in neonatal mortality. The quality of inpatient neonatal care is likely a contributing factor but data from resource limited settings are few. The objective of this study was to assess the quality of neonatal care in the district hospitals of the Kilimanjaro region of Tanzania. Clinical records were reviewed for ill or premature neonates admitted to 13 inpatient health facilities in the Kilimanjaro region; staffing and equipment levels were also assessed. Among the 82 neonates reviewed, key health information was missing from a substantial proportion of records: on maternal antenatal cards, blood group was recorded for 52 (63.4%) mothers, Rhesus (Rh) factor for 39 (47.6%), VDRL for 59 (71.9%) and HIV status for 77 (93.1%). From neonatal clinical records, heart rate was recorded for3 (3.7%) neonates, respiratory rate in 14, (17.1%) and temperature in 33 (40.2%). None of 13 facilities had a functioning premature unit despite calculated gestational age <36 weeks in 45.6% of evaluated neonates. Intravenous fluids and oxygen were available in 9 out of 13 of facilities, while antibiotics and essential basic equipment were available in more than two thirds. Medication dosing errors were common; under-dosage for ampicillin, gentamicin and cloxacillin was found in 44.0%, 37.9% and 50% of cases, respectively, while over-dosage was found in 20.0%, 24.2% and 19.9%, respectively. Physician or assistant physician staffing levels by the WHO indicator levels (WISN) were generally low. Key aspects of neonatal care were found to be poorly documented or incorrectly implemented in this appraisal of neonatal care in Kilimanjaro. Efforts towards quality assurance and enhanced motivation of staff may improve outcomes for this vulnerable group

Implementation experience during an eighteen month intervention to improve paediatric and newborn care in Kenyan district hospitals

<p>Abstract</p> <p>Background</p> <p>We have conducted an intervention study aiming to improve hospital care for children and newborns in Kenya. In judging whether an intervention achieves its aims, an understanding of how it is delivered is essential. Here, we describe how the implementation team delivered the intervention over 18 months and provide some insight into how health workers, the primary targets of the intervention, received it.</p> <p>Methods</p> <p>We used two approaches. First, a description of the intervention is based on an analysis of records of training, supervisory and feedback visits to hospitals, and brief logs of key topics discussed during telephone calls with local hospital facilitators. Record keeping was established at the start of the study for this purpose with analyses conducted at the end of the intervention period. Second, we planned a qualitative study nested within the intervention project and used in-depth interviews and small group discussions to explore health worker and facilitators' perceptions of implementation. After thematic analysis of all interview data, findings were presented, discussed, and revised with the help of hospital facilitators.</p> <p>Results</p> <p>Four hospitals received the full intervention including guidelines, training and two to three monthly support supervision and six monthly performance feedback visits. Supervisor visits, as well as providing an opportunity for interaction with administrators, health workers, and facilitators, were often used for impromptu, limited refresher training or orientation of new staff. The personal links that evolved with senior staff seemed to encourage local commitment to the aims of the intervention. Feedback seemed best provided as open meetings and discussions with administrators and staff. Supervision, although sometimes perceived as fault finding, helped local facilitators become the focal point of much activity including key roles in liaison, local monitoring and feedback, problem solving, and orientation of new staff to guidelines. In four control hospitals receiving a minimal intervention, local supervision and leadership to implement new guidelines, despite their official introduction, were largely absent.</p> <p>Conclusion</p> <p>The actual content of an intervention and how it is implemented and received may be critical determinants of whether it achieves its aims. We have carefully described our intervention approach to facilitate appraisal of the quantitative results of the intervention's effect on quality of care. Our findings suggest ongoing training, external supportive supervision, open feedback, and local facilitation may be valuable additions to more typical in-service training approaches, and may be feasible.</p