Factors influencing referrals for ultrasound-diagnosed complications during prenatal care in five low and middle income countries

BACKGROUND: Ultrasound during antenatal care (ANC) is proposed as a strategy for increasing hospital deliveries for complicated pregnancies and improving maternal, fetal, and neonatal outcomes. The First Look study was a cluster-randomized trial conducted in the Democratic Republic of Congo, Guatemala, Kenya, Pakistan and Zambia to evaluate the impact of ANC-ultrasound on these outcomes. An additional survey was conducted to identify factors influencing women with complicated pregnancies to attend referrals for additional care. METHODS: Women who received referral due to ANC ultrasound findings participated in structured interviews to characterize their experiences. Cochran-Mantel-Haenszel statistics were used to examine differences between women who attended the referral and women who did not. Sonographers\u27 exam findings were compared to referred women\u27s recall. RESULTS: Among 700 referred women, 510 (71%) attended the referral. Among referred women, 97% received a referral card to present at the hospital, 91% were told where to go in the hospital, and 64% were told that the hospital was expecting them. The referred women who were told who to see at the hospital (88% vs 66%), where to go (94% vs 82%), or what should happen, were more likely to attend their referral (68% vs 56%). Barriers to attending referrals were cost, transportation, and distance. Barriers after reaching the hospital were substantial. These included not connecting with an appropriate provider, not knowing where to go, and being told to return later. These barriers at the hospital often led to an unsuccessful referral. CONCLUSIONS: Our study found that ultrasound screening at ANC alone does not adequately address barriers to referrals. Better communication between the sonographer and the patient increases the likelihood of a completed referral. These types of communication include describing the ultrasound findings, including the reason for the referral, to the mother and staff; providing a referral card; describing where to go in the hospital; and explaining the procedures at the hospital. Thus, there are three levels of communication that need to be addressed to increase completion of appropriate referrals-communication between the sonographer and the woman, the sonographer and the clinic staff, and the sonographer and the hospital

Including ultrasound scans in antenatal care in low-resource settings: Considering the complementarity of obstetric ultrasound screening and maternity waiting homes in strengthening referral systems in low-resource, rural settings

Recent World Health Organization (WHO) antenatal care recommendations include an ultrasound scan as a part of routine antenatal care. The First Look Study, referenced in the WHO recommendation, subsequently shows that the routine use of ultrasound during antenatal care in rural, low-income settings did not improve maternal, fetal or neonatal mortality, nor did it increase women\u27s use of antenatal care or the rate of hospital births. This article reviews the First Look Study, reconsidering the assumptions upon which it was built in light of these results, a supplemental descriptive study of interviews with patients and sonographers that participated in the First Look study intervention, and a review of the literature. Two themes surface from this review. The first is that focused emphasis on building the pregnancy risk screening skills of rural primary health care personnel may not lead to adaptations in referral hospital processes that could benefit the patient accordingly. The second is that agency to improve the quality of patient reception at referral hospitals may need to be manufactured for obstetric ultrasound screening, or remote pregnancy risk screening more generally, to have the desired impact. Stemming from the literature, this article goes on to examine the potential for complementarity between obstetric ultrasound screening and another approach encouraged by the WHO, the maternity waiting home. Each approach may address existing shortcomings in how the other is currently understood. This paper concludes by proposing a path toward developing and testing such a hybrid approach

Factor demand linkages, technology shocks, and the business cycle

This paper argues that factor demand linkages can be important for the transmission of both sectoral and aggregate shocks. We show this using a panel of highly disaggregated manufacturing sectors together with sectoral structural VARs. When sectoral interactions are explicitly accounted for, a contemporaneous technology shock to all manufacturing sectors implies a positive response in both output and hours at the aggregate level. Otherwise there is a negative correlation, as in much of the existing literature. Furthermore, we find that technology shocks are important drivers of the business cycle

Notes on beta-deformations of the pure spinor superstring in AdS(5) x S(5)

We study the properties of the vertex operator for the beta-deformation of the superstring in AdS(5) x S(5) in the pure spinor formalism. We discuss the action of supersymmetry on the infinitesimal beta-deformation, the application of the homological perturbation theory, and the relation between the worldsheet description and the spacetime supergravity description.Comment: LaTeX, 74pp

Routine antenatal ultrasound in low- And Middle-income Countries: First look - A cluster randomised trial

Objective: Ultrasound is widely regarded as an important adjunct to antenatal care (ANC) to guide practice and reduce perinatal mortality. We assessed the impact of ANC ultrasound use at health centers in resource-limited countries.Design: Cluster randomized trial.Settings: Clusters within five countries (Democratic Republic of Congo, Guatemala, Kenya, Pakistan and Zambia).Methods: Clusters were randomized to standard ANC or standard care plus two ultrasounds and referral for complications. The study trained providers in intervention clusters to perform basic obstetric ultrasounds.Main Outcome Measures: The primary outcome was a composite of maternal mortality, maternal near-miss mortality, stillbirth, and neonatal mortality.Results: During the 24-month trial, 28 intervention and 28 control clusters had 24,263 and 23,160 births, respectively; 78% in the intervention clusters received at least one study ultrasound; 60% received two. The prevalence of conditions noted including twins, placenta previa and abnormal lie were within expected ranges. 9% were referred for an ultrasound-diagnosed condition and 71% attended the referral. The ANC (RR 1·0 95% CI 1·00, 1·01) and hospital delivery rates for complicated pregnancies (RR 1·03 95% CI 0·89, 1·20) did not differ between intervention and control clusters nor did the composite outcome (RR 1·09 95% CI 0·97, 1·23) or its individual components.Conclusions: Despite availability of ultrasound at ANC in the intervention clusters, neither ANC nor hospital delivery for complicated pregnancies increased. The composite outcome as well as the individual components were not reduced. This article is protected by copyright. All rights reserved

Fermion-Boson Interactions and Quantum Algebras

Quantum Algebras (q-algebras) are used to describe interactions between fermions and bosons. Particularly, the concept of a su_q(2) dynamical symmetry is invoked in order to reproduce the ground state properties of systems of fermions and bosons interacting via schematic forces. The structure of the proposed su_q(2) Hamiltonians, and the meaning of the corresponding deformation parameters, are discussed.Comment: 20 pages, 10 figures. Physical Review C (in press

Cold Atmospheric Pressure Air Plasma Jet for Medical Applications

By flowing atmospheric pressure air through a direct current powered microhollow cathode discharge, we were able to generate a 2 cm long plasma jet. With increasing flow rate, the flow becomes turbulent and temperatures of the jet are reduced to values close to room temperature. Utilizing the jet, yeast grown on agar can be eradicated with a treatment of only a few seconds. Conversely, animal studies show no skin damage even with exposures ten times longer than needed for pathogen extermination. This cold plasma jet provides an effective mode of treatment for yeast infections of the skin

Excited heavy tetraquarks with hidden charm

The masses of the excited heavy tetraquarks with hidden charm are calculated within the relativistic diquark-antidiquark picture. The dynamics of the light quark in a heavy-light diquark is treated completely relativistically. The diquark structure is taken into account by calculating the diquark-gluon form factor. New experimental data on charmonium-like states above open charm threshold are discussed. The obtained results indicate that X(3872), Y(4260), Y(4360), Z(4248), Z(4433) and Y(4660) could be tetraquark states with hidden charm.Comment: 11 page

The No-Pole Condition in Landau gauge: Properties of the Gribov Ghost Form-Factor and a Constraint on the 2d Gluon Propagator

We study the Landau-gauge Gribov ghost form-factor sigma(p^2) for SU(N) Yang-Mills theories in the d-dimensional case. We find a qualitatively different behavior for d=3,4 w.r.t. d=2. In particular, considering any (sufficiently regular) gluon propagator D(p^2) and the one-loop-corrected ghost propagator G(p^2), we prove in the 2d case that sigma(p^2) blows up in the infrared limit p -> 0 as -D(0)\ln(p^2). Thus, for d=2, the no-pole condition \sigma(p^2) 0) can be satisfied only if D(0) = 0. On the contrary, in d=3 and 4, sigma(p^2) is finite also if D(0) > 0. The same results are obtained by evaluating G(p^2) explicitly at one loop, using fitting forms for D(p^2) that describe well the numerical data of D(p^2) in d=2,3,4 in the SU(2) case. These evaluations also show that, if one considers the coupling constant g^2 as a free parameter, G(p^2) admits a one-parameter family of behaviors (labelled by g^2), in agreement with Boucaud et al. In this case the condition sigma(0) <= 1 implies g^2 <= g^2_c, where g^2_c is a 'critical' value. Moreover, a free-like G(p^2) in the infrared limit is obtained for any value of g^2 < g^2_c, while for g^2 = g^2_c one finds an infrared-enhanced G(p^2). Finally, we analyze the Dyson-Schwinger equation (DSE) for sigma(p^2) and show that, for infrared-finite ghost-gluon vertices, one can bound sigma(p^2). Using these bounds we find again that only in the d=2 case does one need to impose D(0) = 0 in order to satisfy the no-pole condition. The d=2 result is also supported by an analysis of the DSE using a spectral representation for G(p^2). Thus, if the no-pole condition is imposed, solving the d=2 DSE cannot lead to a massive behavior for D(p^2). These results apply to any Gribov copy inside the so-called first Gribov horizon, i.e. the 2d result D(0) = 0 is not affected by Gribov noise. These findings are also in agreement with lattice data.Comment: 40 pages, 2 .eps figure

Chemotaxis: a feedback-based computational model robustly predicts multiple aspects of real cell behaviour

The mechanism of eukaryotic chemotaxis remains unclear despite intensive study. The most frequently described mechanism acts through attractants causing actin polymerization, in turn leading to pseudopod formation and cell movement. We recently proposed an alternative mechanism, supported by several lines of data, in which pseudopods are made by a self-generated cycle. If chemoattractants are present, they modulate the cycle rather than directly causing actin polymerization. The aim of this work is to test the explanatory and predictive powers of such pseudopod-based models to predict the complex behaviour of cells in chemotaxis. We have now tested the effectiveness of this mechanism using a computational model of cell movement and chemotaxis based on pseudopod autocatalysis. The model reproduces a surprisingly wide range of existing data about cell movement and chemotaxis. It simulates cell polarization and persistence without stimuli and selection of accurate pseudopods when chemoattractant gradients are present. It predicts both bias of pseudopod position in low chemoattractant gradients and-unexpectedly-lateral pseudopod initiation in high gradients. To test the predictive ability of the model, we looked for untested and novel predictions. One prediction from the model is that the angle between successive pseudopods at the front of the cell will increase in proportion to the difference between the cell's direction and the direction of the gradient. We measured the angles between pseudopods in chemotaxing Dictyostelium cells under different conditions and found the results agreed with the model extremely well. Our model and data together suggest that in rapidly moving cells like Dictyostelium and neutrophils an intrinsic pseudopod cycle lies at the heart of cell motility. This implies that the mechanism behind chemotaxis relies on modification of intrinsic pseudopod behaviour, more than generation of new pseudopods or actin polymerization by chemoattractant