Ethnolinguistic concordance and the receipt of postpartum IUD counseling services in Sri Lanka.

CONTEXT: Ethnic and linguistic concordance are important dimensions of the patient-physician relationship, and are linked to health care disparities. However, evidence on the associations between health behavior and outcomes and patient-provider concordance is limited, especially in low- and middle-income settings. METHODS: To examine how concordance between women and their primary health midwife is associated with women's receipt of postpartum IUD counseling, observational data from a cluster-randomized trial assessing an intervention to increase postpartum IUD counseling were used. Data on 4,497 women who delivered at six hospitals in Sri Lanka between September 2015 and March 2017 were merged with data on 245 primary health midwives, and indicators of linguistic concordance, ethnic concordance and their interaction were generated. Multivariate logistic regression analyses were used to assess the associations between concordance and women's receipt of counseling. RESULTS: Women from non-Sinhalese groups in Sri Lanka face disparities in the receipt of postpartum IUD counseling. Compared with the ethnolinguistic majority (Sinhalese women who speak only Sinhala), non-Sinhalese women have lower odds of having received postpartum IUD counseling, whether they speak both Sinhala and Tamil (odds ratio, 0.6) or only Tamil (0.5). Ethnic discordance- rather than linguistic discordance-is the primary driver of this disparity. CONCLUSIONS: The findings highlight the need for interventions that aim to bridge the sociocultural gaps between providers and patients. Matching women and their providers on ethnolinguistic background may help to reduce disparities in care.Accepted manuscrip

Insecticidal Natural Products From Sri Lankan Plants

This thesis describes investigations of the insecticidal compounds of three Sri Lankan plants, Pleurostylia opposita (Wall) Alston (Celastraceae), Aegle marmelos Correa (Rutaceae) and Excoecaria agallocha Linn. (Euphorbiaceae). After establishing the insecticidal activity of the extracts of three plants, separation of compounds was achieved by bio-assay directed chromatography, and the compounds were characterised by NMR especially 2D experiments, mass, UV and IR spectroscopy. Three new macrocyclic sesquiterpene polyol ester alkaloids 1, 2 and 3 containing a novel 6,7 ring skeleton have been identified from the petroleum ether-ethyl acetate extract of the stem bark of Pleurstylia opposita. They are homologues of known macrocyclic sesquiterpene alkaloids which contains a 6,6 ring system based on the ß-dihydroagarofuran core. The extra methylene has been shown by NMR to be in the 8 position of the 6,7 ring. Observation of insecticidal activity in the Pleurostylia genus is novel. The previously reported 20-hydroxylupane-3- one has also been identified from the active extract and shown to be noninsecticidal. Two new insecticidal compounds 6 and 7 have been identified from the petroleum ether-ethyl acetate extract of the stem bark of Aegle marmelos. They are shown to be protolimonoids, and are senecioate ester analogues of the known isovalerate esters of C-21-ß and C-21-α glabretal which were also isolated. Compounds 8 and 9 were also found to be insecticidal against mustard beetles and houseflies. Separation and characterisation of epimeric mixtures were first achieved for the di p-nitrobenzoate derivative. Previously recorded epoxyaurapten, marmesin, marmin and lupeol have been isolated from the active extract of Aegle marmelos and shown to be noninsecticidal. Five compounds 24-28 have been isolated from the ethyl acetate extract of the stem bark of Excoecaria agallocha. They all have the previously reported daphnane diterpenoid orthoester skeleton, and differ only in the orthoester alkyl side chain. Two of them 24 and 27 are novel. Insecticidal activity has not been recorded previously for extracts of Excoecaria species, nor for the daphnane orthoesters

Massive gastrointestinal haemorrhage from a duodenal diverticulum: a case report

Bleeding duodenal diverticulum is a rare cause of gastrointestinal bleeding, which sometimes can be massive and life threatening. We report one such case and the management, with a successful outcome. Different diagnostic techniques and management options available are also discussed

The effect of a postpartum IUD intervention on counseling and choice: Evidence from a cluster-randomized stepped-wedge trial in Sri Lanka

BACKGROUND: The International Federation of Gynaecology and Obstetrics (FIGO), in collaboration with the Sri Lankan College of Obstetrics and Gynaecologists (SLCOG), launched an initiative in 2014 to institutionalize immediate postpartum IUD (PPIUD) services as a routine part of antenatal counseling and delivery room services in Sri Lanka. In this study, we evaluate the effect of the FIGO-SLCOG PPIUD intervention in six hospitals by means of a cluster-randomized stepped-wedge trial. METHODS/DESIGN: Six hospitals were randomized into two groups of three using matched pairs. Following a 3-month baseline period, the intervention was administered to the first group, while the second group received the intervention after 9 months of baseline data collection. We collected data from 39,084 women who delivered in these hospitals between September 2015 and January 2017. We conduct an intent-to-treat (ITT) analysis to determine the impact of the intervention on PPIUD counseling and choice of PPIUD, as measured by consent to receive a PPIUD, as well as PPIUD uptake (insertion following delivery). We also investigate how factors related to counseling, such as counseling timing and quality, are linked to choice of PPIUD. RESULTS: We find that the intervention increased rates of counseling, from an average counseling rate of 12% in all hospitals prior to the intervention to an average rate of 51% in all hospitals after the rollout of the intervention (0.307; 95% CI 0.148-0.465). In contrast, we find the impact of the intervention on choice of PPIUD to be less robust and mixed, with 4.1% of women choosing PPIUD prior to the intervention compared to 9.8% of women choosing PPIUD after the rollout of the intervention (0.027; 95% CI 0.000-0.054). CONCLUSIONS: This study demonstrates that incorporating PPIUD services into postpartum care is feasible and potentially effective. Taking the evidence on both counseling and choice of PPIUD together, we find that the intervention had a generally positive impact on receipt of PPIUD counseling and, to a lesser degree, on choice of the PPIUD. Nevertheless, it is clear that the intervention's effectiveness can be improved to be able to meet the demand for postpartum family planning of women. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02718222 . Registered on 11 March 2016 (retrospectively registered).Published version and Accepted manuscript versions

Variations on Acoustophoretic Microchannels: From the Facile to the Highly Capable

The lab-on-a-chip toolkit is replete with techniques for microparticle manipulation. The use of ultrasonic waves to impart forces on particles, referred to as acoustophoresis, is one particularly powerful yet gentle option. Traditionally, piezoelectric transducers have been coupled with acoustic resonators in order to sustain standing waves for aggregating, sorting, and sensing applications. However, there are several drawbacks to these setups. First, the construction techniques underpinning resonators tend to be expensive and laborious. Secondly, the acoustic impedance of piezoelectric transducers is much higher than the aqueous medium in which microparticles are suspended. This requires the use of impedance-matching layers to adequately couple acoustic energy into the medium. Finally, piezoelectric materials tend to be incompatible with traditional fabrication methods for microelectromechanical systems (MEMS). This can significantly impact the use of piezoelectric materials in more complex lab-on-a-chip type platforms where many processes beyond sample manipulation may be necessary. Over the past two decades, another type of transducer, known as the capacitive micromachined ultrasonic transducer (CMUT), has been challenging the dominance of the piezotransducer. However, this competition has been occurring primarily in the arenas of non-destructive testing and medical imaging. Given some of the unique attributes of CMUTs, it is surprising that they have yet to be fully realized in acoustophoresis, especially because acoustophoresis is popularly practiced within a microfluidic setting. We first present a highly cost-effective and cleanroom-free technique for prototyping piezo-equipped, transversal acoustophoretic resonators. Simple bifurcation and trifurcation microchannels suitable for acoustophoresis in microscopy applications are fabricated and demonstrated. The second focus of our research looks at the suitability of CMUT microarrays as platforms for acoustophoresis. We address the following: issues surrounding their implementation; modeling of potential resonator designs; and possibility of foregoing resonators altogether. Several CMUT devices are then fabricated and tested, using travelling-wave ultrasound to demonstrate aggregation within droplets as well as sequential capture and separation within flows. A unique phenomenon of bead aggregate palpation is encountered, the physical underpinnings of which are attributed to magnitude changes in lateral gradient forces with frequency. Finally, we attempt to perform standing wave manipulations of particles using the CMUT microarray, and describe the difficulties encountered in doing so

Does lobar intracerebral haemorrhage differ from non-lobar intracerebral haemorrhage?

Spontaneous (non-traumatic) intracerebral haemorrhage accounts for ~10% of all strokes in Western populations. Investigations may identify intracerebral haemorrhage (ICH) as ‘secondary’ to underlying causes such as tumours or aneurysms, but ~80% of ICHs which have no apparent underlying cause (so-called ‘primary’ ICH) tend to be attributed to small vessel vasculopathies such as arteriolosclerosis or cerebral amyloid angiopathy (CAA), on the basis of an adult’s risk factors and clinical and radiographic features of the ICH. The commonly accepted hypothesis is that CAA contributes to lobar ICH and arteriolosclerosis causes non-lobar ICH. In the following thesis, I set out to explore whether (a) the baseline demographic, clinical features and apolipoprotein E genotype of adults with lobar and non-lobar ICH differ, (b) the prognosis of adults with lobar and non-lobar ICH differ and (c) the neuroimaging correlates of small vessel disease in adults with lobar and non-lobar ICH differ since this might provide clues to the vasculopathies underlying lobar and non-lobar ICH. I explored (d) the strength of the association between CAA and ICH by systematically reviewing neuropathological case control studies and (e) the radiological and pathological features of lobar ICH to examine the nature of CAA in persons with lobar ICH and whether any computed tomography (CT) features of ICH are associated with CAA-related lobar ICH. I set up a prospective, community-based inception cohort study of adults with ICH in South East Scotland. Adults with spontaneous primary definite ICH had the opportunity to consent to participate in the Lothian Study of IntraCerebral Haemorrhage, Pathology, Imaging and Neurological Outcome (LINCHPIN), an ethically-approved, prospective community-based research study examining the causes of ICH using apolipoprotein E genotyping, brain MRI and research autopsy in case of death. Of 128 adults with first-ever spontaneous primary definite ICH diagnosed during 2010- 2011, age and pre-morbid hypertension did not differ by ICH location but a history of dementia was more common in adults with lobar ICH. The proportion of adults with one or more non-lobar brain microbleed (BMB) was significantly higher in adults with non-lobar ICH but I did not find any other differences in the severity or distribution of other neuroimaging correlates of small vessel disease between lobar and non-lobar ICH. The apolipoprotein e4 allele was more common in participants with lobar ICH in comparison to those with non-lobar ICH but the frequency of the e2 allele did not differ by ICH location. Adults with lobar ICH were significantly more likely to survive one year after their ICH in comparison to those with non-lobar ICH after adjustment for other known predictors of outcome. From a systematic review of neuropathological case control studies of CAA and ICH, stratified by ICH location, I found a significant association between CAA and lobar ICH but not with ICH in other locations. I examined the radiological and pathological features of 33 adults with first-ever lobar ICH. The presence of CAA or vasculopathy and the severity of CAA in a lobe affected by ICH was concordant with that of the corresponding contralateral unaffected lobe. Capillary CAA was associated with severe CAA. Subarachnoid extension of the ICH tended to be more frequent in those with CAA-related strictly lobar ICH. Having explored the incidence, risk factors and prognosis of lobar and non-lobar ICH, in future work I would aim to establish the strength of the association between CAA and ICH in different brain locations in a neuropathological case control study. Future work should examine the radiopathological features of lobar ICH in a larger cohort and the coexistence of other small vessel diseases, in particular arteriolosclerosis in persons with ICH

Cardiovascular disease risk assessment and reduction: summary of updated NICE guidance

NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the guideline committee's (GC's) experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. Definitions of evidence certainty are given in box 1

Comparison of Solvent-Free Microwave Extraction and Conventional Hydro-Distillation of Essential Oils from four Selected Underutilised Citrus sp. Plants

Essential oils (EOs) are widely used in cosmetic, pharmaceutical, fragrance and food industry. Solvent Free Microwave Extraction (SFME) is a green method for the extraction of essential oils from aromatic plants. The aim of the study is to compare SFME with conventional hydro-distillation (HD) technique, for the extraction of EO from four selected underutilised Citrus plant species in the essential oil industry; Citrus medica, C. reticulata, C. madurensis and C. limon in terms of chemical composition, antioxidant activity and energy consumption. The EOs were extracted using SFME (Microwave power: 700 W for 5 minutes and 400 W for 55 minutes) and HD (for 1 hour) and chemically analysed using Gas Chromatography (GC) and Gas Chromatography and Mass Spectrometry (GC-MS). The Antioxidant activity of the EOs were determined using Ferric Reducing Antioxidant Power (FRAP) and Total Polyphenolic Content (TPC) assays. The GC and GCMS identified 4(10)-Thujene (33.82%) as the major compound in C. medica oil, extracted by HD while that was L- terpinene-4-ol (18%) when extracted by SFME technique. The β-Linalool was the major component in C. reticulata (42.98%) and C. madurensis (37.95%) in SFME extracted EOs, however, it has been dropped down to 26.71% and 26.83% respectively during HD extraction. In C. limon, D-Limonene (43.069%) was abundant in HD- extracted EOs while it was (R)-(+)-Citronellal (39.08%) in SFME-extracted EO. SFME yielded EOs with higher amounts of more valuable oxygenated compounds with higher antioxidant capacities over HD. In comparison with HD, the SFME technique presented higher efficiency with reduced extraction times, costs and energy, yielding EOs with excellent chemical profiles and relatively high antioxidant activity.Keywords: Essential oils, Solvent free Microwave extraction, GC, GCMS, Antioxidan