Scorecards and social accountability for improved maternal and newborn health services: a pilot in the Ashanti and Volta regions of Ghana

Background: With the limited availability of quality emergency obstetric and newborn care (EmONC) in Ghana, and a lack of dialogue on the issue at district level, the Evidence for Action (E4A) program (2011-2015) initiated a pilot intervention using a social accountability approach in two regions of Ghana. Objective: Using scorecards to assess and improve maternal and newborn health services, the intervention study evaluated the effectiveness of engaging multiple, health and non-health sector stakeholders at district level to improve the enabling environment for quality EmONC. Methods: The quantitative study component comprised two rounds of assessments in 37 health facilities. The qualitative component is based on an independent prospective policy study. Results: Results show a marked growth in a culture of accountability, with heightened levels of community participation, transparency, and improved clarity of lines of accountability among decision-makers. The breadth and type of quality of care improvements were dependent on the strength of community and government engagement in the process, especially in regard to more complex systemic changes. Conclusion: Engaging a broad network of stakeholders to support MNH services has great potential if implemented in ways that are context-appropriate and that build around full collaboration with government and civil society stakeholders

Clinical effectiveness and cost-effectiveness of foam sclerotherapy, endovenous laser ablation and surgery for varicose veins: results from the Comparison of LAser, Surgery and foam Sclerotherapy (CLASS) randomised controlled trial.

BACKGROUND: Foam sclerotherapy (foam) and endovenous laser ablation (EVLA) have emerged as alternative treatments to surgery for patients with varicose veins, but uncertainty exists regarding their effectiveness in the medium to longer term. OBJECTIVES: To assess the clinical effectiveness and cost-effectiveness of foam, EVLA and surgery for the treatment of varicose veins. DESIGN: A parallel-group randomised controlled trial (RCT) without blinding, and economic modelling evaluation. SETTING: Eleven UK specialist vascular centres. PARTICIPANTS: Seven hundred and ninety-eight patients with primary varicose veins (foam, n = 292; surgery, n = 294; EVLA, n = 212). INTERVENTIONS: Patients were randomised between all three treatment options (eight centres) or between foam and surgery (three centres). PRIMARY OUTCOME MEASURES: Disease-specific [Aberdeen Varicose Vein Questionnaire (AVVQ)] and generic [European Quality of Life-5 Dimensions (EQ-5D), Short Form questionnaire-36 items (SF-36) physical and mental component scores] quality of life (QoL) at 6 months. Cost-effectiveness as cost per quality-adjusted life-year (QALY) gained. SECONDARY OUTCOME MEASURES: Quality of life at 6 weeks; residual varicose veins; Venous Clinical Severity Score (VCSS); complication rates; return to normal activity; truncal vein ablation rates; and costs. RESULTS: The results appear generalisable in that participants' baseline characteristics (apart from a lower-than-expected proportion of females) and post-treatment improvement in outcomes were comparable with those in other RCTs. The health gain achieved in the AVVQ with foam was significantly lower than with surgery at 6 months [effect size -1.74, 95% confidence interval (CI) -2.97 to -0.50; p = 0.006], but was similar to that achieved with EVLA. The health gain in SF-36 mental component score for foam was worse than that for EVLA (effect size 1.54, 95% CI 0.01 to 3.06; p = 0.048) but similar to that for surgery. There were no differences in EQ-5D or SF-36 component scores in the surgery versus foam or surgery versus EVLA comparisons at 6 months. The trial-based cost-effectiveness analysis showed that, at 6 months, foam had the highest probability of being considered cost-effective at a ceiling willingness-to-pay ratio of £20,000 per QALY. EVLA was found to cost £26,107 per QALY gained versus foam, and was less costly and generated slightly more QALYs than surgery. Markov modelling using trial costs and the limited recurrence data available suggested that, at 5 years, EVLA had the highest probability (≈ 79%) of being cost-effective at conventional thresholds, followed by foam (≈ 17%) and surgery (≈ 5%). With regard to secondary outcomes, health gains at 6 weeks (p < 0.005) were greater for EVLA than for foam (EQ-5D, p = 0.004). There were fewer procedural complications in the EVLA group (1%) than after foam (7%) and surgery (8%) (p < 0.001). Participants returned to a wide range of behaviours more quickly following foam or EVLA than following surgery (p < 0.05). There were no differences in VCSS between the three treatments. Truncal ablation rates were higher for surgery (p < 0.001) and EVLA (p < 0.001) than for foam, and were similar for surgery and EVLA. CONCLUSIONS: Considerations of both the 6-month clinical outcomes and the estimated 5-year cost-effectiveness suggest that EVLA should be considered as the treatment of choice for suitable patients. FUTURE WORK: Five-year trial results are currently being evaluated to compare the cost-effectiveness of foam, surgery and EVLA, and to determine the recurrence rates following each treatment. This trial has highlighted the need for long-term outcome data from RCTs on QoL, recurrence rates and costs for foam sclerotherapy and other endovenous techniques compared against each other and against surgery. TRIAL REGISTRATION: Current Controlled Trials ISRCTN51995477. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 27. See the NIHR Journals Library website for further project information

The Lunacy Commission.

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Stable isotopic evidence for land use patterns in the Middle Euphrates Valley, Syria.

OBJECTIVES: Stable carbon and nitrogen isotope ratios (δ13 C and δ15 N) were used to reconstruct the history of subsistence strategies in the middle Euphrates valley, NE Syria, in six temporal subsets dating from the Early Bronze Age (c. 2300 BCE) to the Modern period (19th/20th century CE). The study aims to demonstrate that changes in political and social organization over time, for which the archaeological record suggests different goals of land use and modes of production, register through dietary patterns that are reflected in isotopic data. MATERIALS AND METHODS: 173 dentin samples were taken from human individuals buried at three sites (Tell Ashara, Tell Masaikh and Gebel Mashtale) together with 15 animal bone samples. Distribution of the δ13 C and δ15 N values in collagen was interpreted in diachronic perspective, and with regard to lifetime shifts between childhood and adolescence. RESULTS: Diachronically, isotope signatures indicate a clear decrease in δ15 N values accompanied by a small shift in δ13 C values between the Old Babylonian (c. 1800-1600 BCE) and the Neo-Assyrian (c. 850-600 BCE) subsets. A major shift in δ13 C values occurred between the Early Islamic (c. 600-1200 CE) and Modern (c. 1800-1950) periods. Ontogenetic changes only occur in a few individuals, but these suggest change of residence between childhood and adolescence. DISCUSSION: The depletion in 15 N from the Neo-Assyrian period onwards is best explained in terms of a shift from intensive to extensive farming, triggered by the fall of regional city-states after the Old Babylonian period and the formation of large supra-regional polities in the Neo-Assyrian period and later. The enrichment in 13 C during the Modern period was most likely the effect of more widely utilizing the dry steppes, abundant in C4 plants, as pasture

Use of whole genome sequencing to determine genetic basis of suspected mitochondrial disorders: cohort study

Funder: University of Cambridge; FundRef: http://dx.doi.org/10.13039/501100000735Funder: Alzheimer's Society; FundRef: http://dx.doi.org/10.13039/501100000320Funder: Leverhulme Trust; FundRef: http://dx.doi.org/10.13039/501100000275Funder: National Institute for Health Research; FundRef: http://dx.doi.org/10.13039/501100000272Funder: Department of Health; FundRef: http://dx.doi.org/10.13039/501100000276Funder: Evelyn Trust; FundRef: http://dx.doi.org/10.13039/501100004282Funder: Wellcome Trust; FundRef: http://dx.doi.org/10.13039/100004440Funder: Medical Research Council; FundRef: http://dx.doi.org/10.13039/501100000265Abstract: Objective: To determine whether whole genome sequencing can be used to define the molecular basis of suspected mitochondrial disease. Design: Cohort study. Setting: National Health Service, England, including secondary and tertiary care. Participants: 345 patients with suspected mitochondrial disorders recruited to the 100 000 Genomes Project in England between 2015 and 2018. Intervention: Short read whole genome sequencing was performed. Nuclear variants were prioritised on the basis of gene panels chosen according to phenotypes, ClinVar pathogenic/likely pathogenic variants, and the top 10 prioritised variants from Exomiser. Mitochondrial DNA variants were called using an in-house pipeline and compared with a list of pathogenic variants. Copy number variants and short tandem repeats for 13 neurological disorders were also analysed. American College of Medical Genetics guidelines were followed for classification of variants. Main outcome measure: Definite or probable genetic diagnosis. Results: A definite or probable genetic diagnosis was identified in 98/319 (31%) families, with an additional 6 (2%) possible diagnoses. Fourteen of the diagnoses (4% of the 319 families) explained only part of the clinical features. A total of 95 different genes were implicated. Of 104 families given a diagnosis, 39 (38%) had a mitochondrial diagnosis and 65 (63%) had a non-mitochondrial diagnosis. Conclusion: Whole genome sequencing is a useful diagnostic test in patients with suspected mitochondrial disorders, yielding a diagnosis in a further 31% after exclusion of common causes. Most diagnoses were non-mitochondrial disorders and included developmental disorders with intellectual disability, epileptic encephalopathies, other metabolic disorders, cardiomyopathies, and leukodystrophies. These would have been missed if a targeted approach was taken, and some have specific treatments

Mass and momentum flux measurements with a high pressure common rail diesel fuel injector

The combined optimization of diesel engine power, fuel consumption, and emissions output significantly drives the development and tuning of engines. One leading subsystem that continues to receive major development and advancement is the fuel system. High pressure common rail systems lead fuel injection technology and utilize both solenoid and piezoelectric actuated injectors with a wide range of pressure and injection scheduling control. To optimize engine operation the fuel system\u27s capability is implemented through complex fuel scheduling coupled with charge preparation. With the number of parameters to control, fuel delivery (including dynamic flow characteristics) is one that must be well understood. Most rate of injection systems provide mass flow rate; however, studies have shown that momentum flux is a critical parameter controlling spray entrainment and penetration. To obtain the mass flow rate and momentum flux for a high pressure common rail diesel fuel injector, a rate of injection meter was designed, constructed, and tested allowing for the dynamic measurement of fuel injection with the capability of in-situ operation in a combustion vessel. Measurements were obtained by recording the force signal from a fuel spray jet impinging on the anvil of a force transducer. Combining the force signal with a measure of cumulative injected mass enables calculation of mass and momentum dynamics. The injection system consisted of a Bosch Generation 2 CRIP 2.2 solenoid controlled fuel injector with a single hole 0.129 mm diameter injector nozzle, driven by a custom programmable injector driver from Southwest Research Institute. Testing control variables were injection pressure and injection duration while using #2 ULSD fuel. Initial results showed high repeatability with a COV of less than 1.1 percent for all injection parameters with an average Cd of 0.92 and Ca of 0.97 for a mean injection pressure of 852 bar. A six point injection pressure sweep from 1000 to 1810 bar showed a 1.74 mg/ms overall increase in injection rate and a 0.16 ms overall decrease in fuel discharge duration. A six point injection duration sweep from 0.25 ms to 1.50 ms showed a 3.36 mg/ms total injection rate increase and a 0.68 ms overall increase in fuel discharge time while maintaining a consistent start-of-injection delay. The results show that this injection rate apparatus provides needed information on injection characteristics to assist engine manufacturers with achieving goals of high power with minimal emissions. Furthermore, it has been shown that this system is versatile for future injector characterizations over a wide range of pressures and durations, along with fuel type and injector parameters including nozzle hole diameter. Copyright © 2010 by ASME