Empowering members of a rural southern community in Nigeria to plan to take action to prevent maternal mortality: a participatory action research project

Aims and objectives. To facilitate the empowerment of members of a rural community to plan to take action to prevent maternal mortality. Background. Globally, about 300,000 maternal deaths occur yearly. Sub-Saharan Africa and Southern Asia regions account for almost all the deaths. Within those regions, India and Nigeria account for over a third of the global maternal deaths. Problem of maternal mortality in Nigeria is multifaceted. About 80% of maternal deaths are avoidable, given strategies which include skilled attendants, emergency obstetric care and community mobilization. In Part One of this article presented here, a strategy of community empowerment to plan to take action to prevent maternal mortality is discussed. Part Two examines evaluation of the actions planned in Part One. Design. Participatory action research was utilized. Methods. Volunteers were recruited as co-researchers into the study through purposive and snowball sampling. Following orientation workshop, participatory data collection was undertaken qualitatively with consequent thematic analysis which formed basis of the plan of action. Results. Community members attributed maternal morbidities and deaths to superstitious causes, delayed referrals by traditional birth attendants, poor transportation and poor resourcing of health facilities. Following critical reflection, actions were planned to empower the people to prevent maternal deaths through: community education and 2 advocacy meetings with stakeholders to improve health and transportation infrastructures; training of existing traditional birth attendants in the interim and initiating their collaboration with skilled birth attendants. Conclusion. The community is a resource which if mobilized through the process of participatory action research, can be empowered to plan to take action in collaboration with skilled birth attendants to prevent maternal mortality. Relevance to clinical practice. InterventioAims and objectives. To facilitate the empowerment of members of a rural community to plan to take action to prevent maternal mortality. Background. Globally, about 300,000 maternal deaths occur yearly. Sub-Saharan Africa and Southern Asia regions account for almost all the deaths. Within those regions, India and Nigeria account for over a third of the global maternal deaths. Problem of maternal mortality in Nigeria is multifaceted. About 80% of maternal deaths are avoidable, given strategies which include skilled attendants, emergency obstetric care and community mobilization. In Part One of this article presented here, a strategy of community empowerment to plan to take action to prevent maternal mortality is discussed. Part Two examines evaluation of the actions planned in Part One. Design. Participatory action research was utilized. Methods. Volunteers were recruited as co-researchers into the study through purposive and snowball sampling. Following orientation workshop, participatory data collection was undertaken qualitatively with consequent thematic analysis which formed basis of the plan of action. Results. Community members attributed maternal morbidities and deaths to superstitious causes, delayed referrals by traditional birth attendants, poor transportation and poor resourcing of health facilities. Following critical reflection, actions were planned to empower the people to prevent maternal deaths through: community education and 2 advocacy meetings with stakeholders to improve health and transportation infrastructures; training of existing traditional birth attendants in the interim and initiating their collaboration with skilled birth attendants. Conclusion. The community is a resource which if mobilized through the process of participatory action research, can be empowered to plan to take action in collaboration with skilled birth attendants to prevent maternal mortality. Relevance to clinical practice. InterventioAims and objectives. To facilitate the empowerment of members of a rural community to plan to take action to prevent maternal mortality. Background. Globally, about 300,000 maternal deaths occur yearly. Sub-Saharan Africa and Southern Asia regions account for almost all the deaths. Within those regions, India and Nigeria account for over a third of the global maternal deaths. Problem of maternal mortality in Nigeria is multifaceted. About 80% of maternal deaths are avoidable, given strategies which include skilled attendants, emergency obstetric care and community mobilization. In Part One of this article presented here, a strategy of community empowerment to plan to take action to prevent maternal mortality is discussed. Part Two examines evaluation of the actions planned in Part One. Design. Participatory action research was utilized. Methods. Volunteers were recruited as co-researchers into the study through purposive and snowball sampling. Following orientation workshop, participatory data collection was undertaken qualitatively with consequent thematic analysis which formed basis of the plan of action. Results. Community members attributed maternal morbidities and deaths to superstitious causes, delayed referrals by traditional birth attendants, poor transportation and poor resourcing of health facilities. Following critical reflection, actions were planned to empower the people to prevent maternal deaths through: community education and 2 advocacy meetings with stakeholders to improve health and transportation infrastructures; training of existing traditional birth attendants in the interim and initiating their collaboration with skilled birth attendants. Conclusion. The community is a resource which if mobilized through the process of participatory action research, can be empowered to plan to take action in collaboration with skilled birth attendants to prevent maternal mortality. Relevance to clinical practice. InterventioInterventions to prevent maternal deaths should include community empowerment to have better understanding of their circumstances as well as their collaboration with health professionals

Red Blood Cell Clearance in Inflammation

Anemia is a frequently encountered problem in the critically ill patient. The inability to compensate for anemia includes several mechanisms, collectively referred to as anemia of inflammation: reduced production of erythropoietin, impaired bone marrow response to erythropoietin, reduced iron availability, and increased red blood cell (RBC) clearance. This review focuses on mechanisms of RBC clearance during inflammation. We state that phosphatidylserine (PS) expression in inflammation is mainly enhanced due to an increase in ceramide, caused by an increase in sphingomyelinase activity due to either platelet activating factor, tumor necrosis factor, or direct production by bacteria. Phagocytosis of RBCs during inflammation is mediated via RBC membrane protein band 3. Reduced deformability of RBCs seems an important feature in inflammation, also mediated by band 3 as well as by nitric oxide, reactive oxygen species, and sialic acid residues. Also, adherence of RBCs to the endothelium is increased during inflammation, most likely due to increased expression of endothelial adhesion molecules as well as PS on the RBC membrane, in combination with decreased capillary blood flow. Thereby, clearance of RBCs during inflammation shows similarities to clearance of senescent RBCs, but also has distinct entities, including increased adhesion to the endotheliu

Extracellular Vesicles from Red Blood Cell Products Induce a Strong Pro-Inflammatory Host Response, Dependent on Both Numbers and Storage Duration

Background: Transfusion of red blood cells (RBCs) is associated with adverse outcome, but the causative factor is unknown. Extracellular vesicles (EVs) have pro-inflammatory properties. We hypothesized that EVs released from both fresh and stored RBC products can induce a host inflammatory response in a dose-dependent manner. Methods: Whole blood was incubated with supernatant from RBC units stored for different time periods, either containing (different numbers of) EVs or depleted from EVs. Results: Incubation with both fresh and stored supernatant containing EVs induced a strong host response with production of TNF, IL-6 and IL-8. In supernatant depleted from EVs, this host response was completely abrogated. IL-10 levels were not affected. EV-induced host response was both dependent on the number of EVs as well as on storage time. Conclusions: EVs from both fresh and stored RBC units illicit a strong inflammatory host response in recipients and may therefore contribute to adverse outcome of RBC transfusion. (C) 2015 S. Karger GmbH, Freibur

ENDOTOXEMIA RESULTS IN TRAPPING OF TRANSFUSED RED BLOOD CELLS IN LUNGS WITH ASSOCIATED LUNG INJURY

Background: Red blood cell (RBC) transfusion is associated with organ failure, in particular in the critically ill. We hypothesized that endotoxemia contributes to increased trapping of RBCs in organs. Furthermore, we hypothesized that this effect is more pronounced following transfusion of stored RBCs compared with fresh RBCs. Methods: Adult male Sprague-Dawley rats were randomized to receive injection with lipopolysaccharide from E coli or vehicle and transfusion with fresh or stored biotinylated RBCs. After 24 h, the amount of biotinylated RBCs in organs was measured by flow cytometry, as well as the 24-h post-transfusion recovery. Markers of organ injury and histopathology of organs were assessed. Results: Endotoxemia resulted in systemic inflammation and organ injury. Following RBC transfusion, donor RBCs were recovered from the lung and kidney of endotoxemic recipients (1.2 [0.8-1.6]% and 2.2 [0.4-4.4]% of donor RBCs respectively), but not from organs of healthy recipients. Trapping of donor RBCs in the lung was associated with increased lung injury, but not with kidney injury. Stored RBCs induced organ injury in the spleen and yielded a lower 24-h post-transfusion recovery, but other effects of storage time were limited. Conclusion: Endotoxemia results in an increased percentage of donor RBCs recovered from the lung and kidney, which is associated with lung injury following transfusio

Effect of red blood cell transfusion on inflammation, endothelial cell activation and coagulation in the critically ill

Background and Objectives: Red blood cell (RBC) transfusion is a frequently applied intervention in an intensive care unit. However, transfusion is associated with adverse outcomes including organ failure and thrombo-embolic events. Mechanisms of these effects are not known but may be related to activation of the endothelium or of the coagulation or inflammatory system. We hypothesized that a RBC transfusion in the critically ill would result in further activation of these systems. Materials and Methods: In 74 non-bleeding critically ill patients receiving one RBC unit, markers of inflammation, endothelial cell activation and coagulation were measured before transfusion, at 1 h after transfusion and 24 h after transfusion. The impact of disease severity of the recipient on these changes was assessed by comparing septic and non-septic patients (according to sepsis-3 definition) and by correlation of biomarkers with the sequential organ failure assessment (SOFA) score. Results: Levels of von Willebrand Factor (vWF), soluble ICAM-1, soluble thrombomodulin, fibrinogen and d-dimer were already high at baseline, whereas ADAMTS13 levels were low. VWF levels increased significantly 24 h after RBC transfusion (median 478% (338–597) vs. 526% (395–623), p = 0.009). The other biomarkers did not change significantly. Post transfusion change was not dependent on the presence of sepsis and was not correlated with SOFA score. Conclusion: RBC transfusion in critically ill patients was associated with an increase in circulating vWF levels, suggesting a further increase in activation of the endothelium, a finding that was independent of the presence of sepsis or organ injury level

Transfusion of platelets, but not of red blood cells, is independently associated with nosocomial infections in the critically ill

Background: Red blood cell (RBC) transfusion has been associated with nosocomial infection in the critically ill patients. However, this association may be confounded by length of stay, as prolonged intensive care unit (ICU stay) increases both risk of infection and risk of transfusion. Also, it is not known whether specific blood products have differential risks. Methods: In this prospective multicentre cohort study, the risk of bacterial infections associated with transfusion products in critically ill (ICU) patients was determined in an integrated statistical model, using Cox proportional hazard analysis to account for attrition bias. In all acutely admitted patients with a length of stay of >48 h between 1 January 2011 and 31 December 2012, the occurrence of nosocomial infections in the ICU was prospectively monitored using CDC criteria. Results Of 3502 screened patients, 476 (13.6 %) developed a nosocomial infection. These patients had higher APACHE IV scores, had longer ICU length of stay and were more frequently transfused compared to patients without an infection. Logistic regression showed that RBC transfusion was a risk factor for infection [odds ratio (OR) 1.98, 95 % confidence interval (CI) 1.54–2.55, p < 0.001], as well the number of RBC units transfused (OR 1.04, 95 % CI 1.03–1.06, p < 0.001). However, these associations disappeared in the Cox proportional hazard analysis. In contrast, we found an association between plasma transfusion and infection [hazard ratio (HR) 1.36, 95 % CI 1.10–1.69, p = 0.004] and between platelet transfusion and infection (HR 1.46, 95 % CI 1.18–1.81, p < 0.001). However, only platelet transfusion was associated with infection independently from other transfusion products (HR 1.40, 95 % CI 1.03–1.90, p = 0.03). Conclusions In critically ill patients, transfusion of platelets, but not of RBCs and plasma, is an independent risk factor for acquiring a nosocomial infection

Transfusion of fresh-frozen plasma in critically ill patients with a coagulopathy before invasive procedures: a randomized clinical trial (CME)

Prophylactic use of fresh-frozen plasma (FFP) is common practice in patients with a coagulopathy undergoing an invasive procedure. Evidence that FFP prevents bleeding is lacking, while risks of transfusion-related morbidity after FFP have been well demonstrated. We aimed to assess whether omitting prophylactic FFP transfusion in nonbleeding critically ill patients with a coagulopathy who undergo an intervention is noninferior to a prophylactic transfusion of FFP. A multicenter randomized open-label trial with blinded endpoint evaluation was performed in critically ill patients with a prolonged international normalized ratio (INR; 1.5-3.0). Patients undergoing placement of a central venous catheter, percutaneous tracheostomy, chest tube, or abscess drainage were eligible. Patients with clinically overt bleeding, thrombocytopenia, or therapeutic use of anticoagulants were excluded. Patients were randomly assigned to omitting or administering a prophylactic transfusion of FFP (12 mL/kg). Outcomes were occurrence of postprocedural bleeding complications, INR correction, and occurrence of lung injury. Due to slow inclusion, the trial was stopped before the predefined target enrollment was reached. Eighty-one patients were randomly assigned, 40 to FFP and 41 to no FFP transfusion. Incidence of bleeding did not differ between groups, with a total of one major and 13 minor bleedings (p = 0.08 for noninferiority). FFP transfusion resulted in a reduction of INR to less than 1.5 in 54% of transfused patients. No differences in lung injury scores were observed. In critically ill patients undergoing an invasive procedure, no difference in bleeding complications was found regardless whether FFP was prophylactically administered or no

The effect of red blood cell transfusion on iron metabolism in critically ill patients

BACKGROUND: Anemia of inflammation (AI) has a high prevalence in critically ill patients. In AI, iron metabolism is altered, as high levels of inflammation-induced hepcidin reduce the amount of iron available for erythropoiesis. AI is treated with red blood cell (RBC) transfusions. The effect of RBC transfusion on iron metabolism during inflammatory processes in adults is unknown. We investigated the effect of RBC transfusion on iron metabolism in critically ill patients. METHODS: In a prospective cohort study in 61 critically ill patients who received 1 RBC unit, levels of iron variables were determined before, directly after, and 24 hours after transfusion in septic and nonseptic patients. RESULTS: Serum iron levels were low and increased after transfusion (p = 0.02). However, RBC transfusion had no effect on transferrin saturation (p = 0.14) and ferritin levels (p = 0.74). Hepcidin levels increased after RBC transfusion (p = 0.01), while interleukin-6 levels decreased (p = 0.03). In septic patients, RBC transfusion induced a decrease in haptoglobin levels compared to baseline, which did not occur in nonseptic patients (p = 0.01). The effect of RBC transfusion on other iron variables did not differ between septic and nonseptic patients. CONCLUSION: Transfusion of a RBC unit transiently increases serum iron levels in intensive care unit patients. The increase in hepcidin levels after transfusion can further decrease iron release from intracellular storage making it available for erythropoiesis. RBC transfusion is associated with a decrease in haptoglobin levels in septic compared to nonseptic patients, but did not affect other markers of hemolysis