"We restrict certain things": a cross-sectional study of health provider adherence to WHO's recommendation for intrapartum oral intake of fluid and food in Greater Accra, Ghana.

BACKGROUND: Since 2018, WHO recommends oral fluid and food intake for low-risk women during labor to enhance positive childbirth experience and respect for women's preferences. This study investigated the current practices related to intrapartum oral intake among maternity care providers and women in public health facilities in Greater Accra, Ghana, and explored barriers and opportunities for adherence to the WHO guidance. METHODS: We used a mixed-method design at five public health facilities in Greater Accra, Ghana, which included structured interviews with 11 facility-level quality improvement staff and 12 maternity care providers; a knowledge, attitudes, and practices survey with the same providers; and a client survey with 56 inpatient postpartum women. We conducted descriptive and inferential statistics, including z-tests to assess independent and dependent variables, and inductive thematic analyses. RESULTS: Provider adherence to the WHO recommendation varied, with many imposing restrictions on oral intake during labor. Concerns included potential complications like Mendelson's syndrome, consequently framing oral intake decisions as clinical and leading providers to limit women's involvement in their care decisions. Within our sample, 54% and 43% women reported their provider counseled them on oral fluid and food intake respectively, while 41% and 34% reported their provider asked them their preference for drinking and eating respectively. Ultimately, 73% drank fluids and 19% ate food during their labor. Counseling significantly correlated with women's intake practices (p < 0.01) and providers' inquiry to women's preferences for drinking and eating (p < 0.001) during labor. CONCLUSION: Adherence to evidence-based practices for intrapartum oral intake among low-risk women was inconsistence. Maternity care providers play a vital role in involving women in their care decisions and respecting women's preferences. Strengthening national-level labor care guidelines and provider quality improvement approaches like in-service training, supportive supervision, and job aides to include the WHO recommendation will help providers adhere to the guidance and contribute to promoting a positive childbirth experience for women.

'R' you ready to save time? Using R to facilitate question creation in a pharmaceutical calculations course.

BACKGROUND AND PURPOSE: Pharmacists are expected to perform quick and accurate calculations throughout their careers. To achieve a proficient skill level, student pharmacists need ample and varied opportunities to practice pharmaceutical calculations. However, the creation of practice modalities can be time-consuming and labor-intensive for instructors. EDUCATIONAL ACTIVITY AND SETTING: We used the statistical analysis programming language R to create an efficient method to generate multiple variations of existing calculation questions. The method was evaluated with a group of student pharmacists as part of an 11-week calculations course. FINDINGS: This process can be challenging to set up initially. The method was able to generate over 100 variations of each calculation question. The student pharmacists who participated in the pilot study found the method to be easy to use and helpful for practicing pharmaceutical calculations. SUMMARY: We have developed an efficient method to generate multiple variations of existing calculation questions. This method can be used to create practice modalities that are more varied and challenging, which can help student pharmacists develop the skills they need to perform accurate calculations in their future careers.

Safety and efficacy of methylprednisolone versus dexamethasone in critically ill patients with COVID-19 acute respiratory distress syndrome: a retrospective study.

Background: Corticosteroids (CSs), specifically dexamethasone (DEX), are the treatment of choice for severe acute respiratory distress syndrome (ARDS) due to COVID-19 pneumonia (CARDS). However, data from both ARDS and relatively small CARDS clinical trials have suggested improved outcomes with methylprednisolone (MP) versus DEX. The objective of this retrospective cohort study was to compare the safety and effectiveness of MP and DEX in critically ill CARDS patients. Methods: The study cohort included CARDS patients admitted to a tertiary referral intensive care unit (ICU) between April and September 2020 who received at least 5 days of CSs for CARDS. Results: The cohort was notable for a high severity of illness (overall, 88.5% of patients required mechanical ventilation and 16% required vasopressors on admission). The DEX group (n = 62) was significantly older with a higher illness severity [Sequential Organ Failure Assessment (SOFA) 6 (4.75-8) versus 4.5 (3-7), p = 0.008], while the MP group (n = 51) received significantly more loading doses [19 (37.3%) versus 4 (6.5%), p < 0.0001]. MP was associated with a shorter time to intubation and more rapid progression to mortality [days to death: 18 (15-23) versus 27 (15-34), p = 0.026]. After correction for baseline imbalances in age and SOFA score, DEX was associated with improved mortality at 90 days compared with MP [hazard ratio (HR) = 0.43, 95% confidence interval (CI) = 0.23-0.80, p = 0.008]. However, there were no differences between rates of secondary infections during hospitalization or insulin requirements at 7 and 14 days. Conclusion: In this cohort of critically ill CARDS, choice of CS was associated with mortality but not adverse event profile, and thus warrants further investigation.

Faculty Doing More with Less: A Technology Initiative Realized Through a Structured Process.

Introduction: Many barriers exist when implementing new educational technologies. Some institutions without specialty support staff or offices may struggle with the necessary steps. In a climate that increasingly asks faculty to do more with less, empowering faculty-driven processes may prove important. Innovation: When the need for an academic electronic health record (EHR) was identified, a faculty champion followed a structured approach to research available options, garner faculty interest, bring forth a proposal to the administration, implement the academic EHR technology, and perform continuous quality improvement thereby paving the pathway for future faculty-led initiatives. Findings: A single faculty member followed a structured approach that could be carried out by others to bring meaningful academic technology to multiple programs. This process was subsequently successfully used by another faculty member and the technology implemented was well-received by administration, faculty, and students. Conclusion: Despite few resources to support or compel technological adaptation or change, faculty can follow steps to introduce these projects and moreover, spark a cultural shift and momentum to embolden faculty to follow a process to bring forth change or initiatives in the future.

Reducing Barriers to Postabortion Contraception: The Role of Expanding Coverage of Postabortion Care in Dar es Salaam, Tanzania.

BACKGROUND: In Tanzania, limited access to postabortion care (PAC) contributes to high rates of maternal mortality. To address the issue, Pathfinder International and the Tanzania Ministry of Health, Community Development, Gender, Elderly and Children (MOHCDGEC) introduced and expanded coverage of PAC in 64 public health facilities in Dar es Salaam, Tanzania. METHODS: During a 30-month period, we implemented a multifaceted approach to introduce and expand PAC, including clinical training and mentorship for health care providers; service reorganization, equipment provision, and an expanded method mix offering; standardization of PAC reporting tools; and community engagement and referral. We assessed outcomes using PAC service statistics from 64 public health facilities in 4 districts of Dar es Salaam and health care provider mentorship data from 385 observed PAC visits. RESULTS: From January 2016 to June 2018, voluntary postabortion contraceptive uptake increased steadily. A total of 6,636 PAC clients, including 2,731 young people (ages 10-24), adopted a method post-procedure. Average semesterly client volume per facility increased from 27 to 52.4 manual vacuum aspiration clients and 17.6 to 43.9 postabortion contraceptors between the first and last periods. Overall postabortion contraceptive uptake was 80.6% (6,636/8,230), with a method mix of 58.3% implant, 18.9% intrauterine device, 13.7% pills, 8.6% injectables, and 0.5% permanent methods. Adults and young people had comparable method mix. Mentored providers showed improvements in service quality indicators. During the last period, 92% counseled the client on contraception, 93% considered the client's sexual and reproductive health intentions, 94% provided correct method information and supply, and 96% documented services on the client's family planning card. Different provider types (mid- and senior-level) performed comparably. CONCLUSIONS: Expanding PAC coverage to primary- and secondary-level facilities led to high uptake of voluntary contraception among postabortion clients. Key interventions included PAC clinical training and mentorship; service reorganization, equipment provision, and an expanded method mix offering; use of standardized PAC registers; and community engagement for awareness building and linkage to PAC.

First trimester ferritin screening for pre-delivery anaemia as a patient blood management strategy.

OBJECTIVES: To determine the optimum approach and timing to screen for iron deficiency in pregnancy. BACKGROUND: There is a lack of consensus on identifying and treating iron deficiency during pregnancy. Patient blood management programs may be refined by evaluating outcomes. METHODS: Retrospective data collection on women delivering prior to and following implementation of patient blood management interventions. Ferritin, transferrin saturation and haemoglobin levels were evaluated in first and second trimesters as predictors of pre-delivery anaemia. The optimum time to screen was determined. Comparison with results following a quality improvement intervention was undertaken. A separate retrospective study was performed to validate the predictive value of ferritin using data extracted from the laboratory information system. RESULTS: Ferritin and transferrin saturation in first trimester detected women who subsequently had anaemia pre-delivery, with ferritin being most discriminatory. Both were superior to haemoglobin concentration. Iron studies in second trimester did not predict pre-delivery anaemia and haemoglobin remained poorly discriminatory. Iron studies lost predictive value when a systematic program ensured treatment of iron depletion during pregnancy. The ability of ferritin to predict pre-delivery anaemia in the first, but not the second, trimester was confirmed on the validation cohort. CONCLUSION: First trimester serum ferritin may identify candidates for iron therapy during pregnancy. This strategy may be preferable to haemoglobin screening alone or universal replacement in centres at low risk of anaemia.

Case Report: Fulminant Murine Typhus Presenting with Status Epilepticus and Multi-Organ Failure: an Autopsy Case and a Review of the Neurologic Presentations of Murine Typhus.

Murine typhus (MT) is an important cause of febrile illness in endemic areas, and there is an epidemiologic resurgence of this infection currently transpiring in Texas and California. Fatal cases and severe neurological complications are rare. A fatal case of MT in a middle-aged man is reported with a course culminating in multi-organ failure and refractory status epilepticus. An autopsy revealed hemorrhagic pneumonia, acute tubular necrosis, and ischemic necrosis in the liver, adrenals, and brain. We have also reviewed the neurologic complications of MT.

Anisotropic and Multicomponent Nanostructures by Controlled Symmetry Breaking of Metal Halide Intermediates.

We propose and validate herein a solution-phase synthetic strategy relying on in situ photostimulation and reduction of metal-halide intermediates to yield complex anisotropic and multicomponent nanostructures. Exposure of AgBr nanoparticles to ultraviolet light and l-Arginine forms dimers composed of crystalline Ag and AgBr nanophases. The Ag nanoparticle nucleates at and grows from a single point on the surface of the AgBr phase and the interface connecting these phases is atomically sharp. The complex nanostructures are generated at greater than 80% yield and are highly monodisperse in morphology and in size. The high crystallinity of the nanophases arises from an apparent solid-solid crystallization process and is unusual considering the nearly 40% lattice mismatch between Ag and AgBr. Such structures may be used to interrogate photocatalytic mechanisms or to construct more complex materials.

Postpartum obstetric red cell transfusion practice: A retrospective study in a tertiary obstetric centre.

BACKGROUND: Traditional management of anaemia due to postpartum haemorrhage (PPH) has relied upon salvage therapy with red cell transfusion. Recently published guidance recommends a change in approach toward holistic patient blood management. AIMS: To determine whether postpartum red cell transfusion practices are consistent with best practice and to identify opportunities for improvement. MATERIALS AND METHODS: A retrospective audit of postpartum red cell transfusions was conducted at a tertiary level obstetrics unit. Relevant clinical and laboratory data were collected for all cases of postpartum red cell transfusions and PPH. Clinical decision making and appropriateness of transfusions were evaluated. RESULTS: Among the 3235 women who delivered in 2013, 110 (3.4%) received a postpartum red cell transfusion. About 101 of the transfusions were associated with primary PPH. Overall PPH complicated 460 (14.2%) deliveries. Antenatal anaemia was identified as a major correctable risk factor for transfusion in women who experienced PPH (odds ratio 6.55, 95% CI: 3.17-13.6). Volume of blood loss and the aetiology of PPH were additional risk factors for transfusion. Transfusion was associated with lower birth weight and increased maternal length of stay. Transfusion triggers were more likely to be appropriate when transfusion took place in the operating theatre, within 12 h of delivery and when prescribed by anaesthetists. Post-transfusion Hb levels were uniformly above target for all women transfused. CONCLUSIONS: A significant number of red cell transfusions were outside the recommendations of the new guidelines. Maximising red cell mass during pregnancy and improving transfusion practices were identified as opportunities for future improvement.

Observers' Judgments of the Effects of Glare on Their Visual Acuity for High and Low Contrast Stimuli.

Disability glare refers to a reduction in the ability to discern a stimulus that is positioned near another stimulus that has a much higher luminance. While it is common for drivers to report that they have been "blinded" by oncoming headlights, it is unclear whether observers can accurately judge when they are visually disabled by glare. This experiment sought to quantify the accuracy with which observers can judge when a glare source reduces their visual acuity. Seventeen observers estimated their disability glare threshold (DGT)-the luminance of a glare source that would be just sufficient to impair their ability to discern the orientation of a Landolt C that was surrounded by the glare source. These estimated DGTs were compared to the participant's actual DGTs. Participants consistently underestimated the intensity of glare that was required to impair their acuity. On average, estimates of glare threshold were 88% lower than actual glare threshold intensities. Participants' judgments were affected by stimulus size but not stimulus contrast. These results suggest that observers can exaggerate the debilitating effects of glare and that they can fail to appreciate that high contrast stimuli are more robust to glare. A driver who believes that even the lowest intensities of headlight glare can visually impair an oncoming driver may be reluctant to use high beam headlamps, despite their significant visibility advantages.

A regio- and diastereoselective intramolecular nitrone cycloaddition for practical 3- and 2,3-disubstituted piperidine synthesis from gamma-butyrolactone.

A fast and efficient route for diversity-oriented synthesis of 3- and 2,3-disubstituted piperidines, featuring an intramolecular nitrone cycloaddition with high regio- and diastereoselectivity, was achieved in six steps and 36-66% overall yield from commercially available gamma-butyrolactone or 1,4-butanediol. A new N-alkenyl nitrone enoate was used in this intramolecular nitrone cycloaddition, and the regioselectivity, diastereoselectivity, and reversibility of this cycloaddition were investigated.

Random sampling of states in dynamic programming.

We combine three threads of research on approximate dynamic programming: sparse random sampling of states, value function and policy approximation using local models, and using local trajectory optimizers to globally optimize a policy and associated value function. Our focus is on finding steady-state policies for deterministic time-invariant discrete time control problems with continuous states and actions often found in robotics. In this paper, we describe our approach and provide initial results on several simulated robotics problems.

Neurone specific regulation of dendritic spines in vivo by post synaptic density 95 protein (PSD-95).

Post synaptic density protein 95 (PSD-95) is a postsynaptic adaptor protein coupling the NMDA receptor to downstream signalling pathways underlying plasticity. Mice carrying a targeted gene mutation of PSD-95 show altered behavioural plasticity including spatial learning, neuropathic pain, orientation preference in visual cortical cells, and cocaine sensitisation. These behavioural effects are accompanied by changes in long-term potentiation of synaptic transmission. In vitro studies of PSD-95 signalling indicate that it may play a role in regulating dendritic spine structure. Here, we show that PSD-95 mutant mice have alterations in dendritic spine density in the striatum (a 15% decrease along the dendritic length) and in the hippocampus (a localised 40% increase) without changes in dendritic branch patterns or gross neuronal architecture. These changes in spine density were accompanied by altered expression of proteins known to interact with PSD-95, including NR2B and SAP102, suggesting that PSD-95 plays a role in regulating the expression and activation of proteins found within the NMDA receptor complex. Thus, PSD-95 is an important regulator of neuronal structure as well as plasticity in vivo.

Widespread loss of neuronal populations in the spinal ventral horn in sporadic motor neuron disease. A morphometric study.

The cytopathology and loss of neurons was studied in 7670 neurons from the ventral horn of the third lumbar segment of the spinal cord of six sporadic motor neuron disease (MND) patients compared with 7568 neurons in seven age matched control subjects. A modified Tomlinson et al. [Tomlinson BE, Irving D, Rebeiz JJ. Total numbers of limb motor neurones in the human lumbosacral cord and an analysis of the accuracy of various sampling procedures. J Neurol Sci 1973;20:313-27] sampling procedure was used for neuronal counts. The ventral horn was divided in quadrants. Neuronal populations were also classified by the maximum cell diameter through the nucleolus. There was widespread loss of neurons in all quadrants of the ventral horn in MND. Size distribution histograms showed similar neuron loss across all populations of neurons. The dorsomedial quadrant contains almost exclusively interneurons and the ventrolateral quadrant mostly motor neurons. The cytopathology of neurons in the dorsomedial quadrant and of large motorneurons in the ventrolateral quadrant MND was similar. In the dorsomedial quadrant, neuron loss (56.7%) was similar to the loss of large motor neurons in the ventrolateral quadrant (64.4%). The loss of presumed motor neurons and interneurons increased with increased disease duration. There was no evidence that loss of presumed interneurons occurred prior, or subsequent, to loss of motor neurons. We conclude that, in sporadic MND, all neuronal populations in the ventral horn are affected and that interneurons are involved to a similar extent and in parallel with motor neurons, as reported in the G86R transgenic mouse model of familial MND. The increasing evidence of loss of neurons other than motor neurons in MND suggests the need for revising the concept of selective motor neuron vulnerability.