Provider experiences with uterine balloon tamponade for uncontrolled postpartum hemorrhage in health facilities in Kenya.

OBJECTIVE: To understand provider perceptions and experiences following training in the use of a condom-catheter uterine balloon tamponade (UBT) as second-line treatment for uncontrolled postpartum hemorrhage (PPH) in health facilities in Kenya. METHODS: As part of a qualitative study, interviews of facility-based providers who had managed PPH following comprehensive PPH training were conducted between February and April 2014. Facilities were purposively sampled to represent a range of experience with UBT, facility size, and geography. Interviews continued until thematic saturation was achieved. Interview transcripts were analyzed for themes. RESULTS: Overall, 68 providers from 29 facilities were interviewed, of whom 31 reported experience with UBT placement (25 midwives, 2 clinical officers, 4 medical officers). Qualitative analysis revealed several major themes. Providers used UBT appropriately within the PPH algorithm, although the timing and clinical severity of patients varied. UBT was most commonly used when bleeding was unresponsive to uterotonics, hysterectomy was unavailable, and referral times long. Providers reported that bleeding was arrested following UBT use in all except one patient, who had a suspected coagulopathy. Most providers described UBT as technically easy to use, although three described initial balloon displacement. CONCLUSION: UBT has been readily accepted by providers at all levels of training and is being incorporated into the existing PPH management algorithm in Kenya.

Defining the anesthesia gap for reproductive health procedures in resource-limited settings.

BACKGROUND: In resource-limited settings, severe shortages of anesthetists and anesthesiologists lead to surgical delays that increase maternal and neonatal mortality and morbidity. OBJECTIVES: To more clearly understand the individual components of the anesthesia gap pertaining to reproductive health surgeries and procedures in resource-limited settings. SEARCH STRATEGY: Medline, the Cochrane Library, CINAHL, Embase, and POPLINE were systematically searched for reports published before December 31, 2013. Search terms were related to obstetric surgery, resource-limited settings, and anesthesia. SELECTION CRITERIA: Studies that addressed the use of anesthesia in reproductive procedures in resource-limited settings were included. DATA COLLECTION AND ANALYSIS: Reviewers independently evaluated the full text of identified studies, extracted information related to study objectives and conclusions, and identified the anesthesia gap. MAIN RESULTS: Overall, 14 publications met the inclusion criteria. A significant lack of infrastructure, equipment and supplies, and trained personnel were identified as key factors responsible for a lack of anesthesia services. CONCLUSIONS: A shortage of trained anesthesia providers, equipment, supplies, medications, and infrastructure, along with limitations in transportation in resource-limited settings have produced a wide gap between available anesthesia services and the demand for them for reproductive health surgeries and procedures. Safe, affordable, and scalable solutions to address the anesthesia gap are urgently needed.

Thrombolysis in myocardial infarction risk score in an observation unit setting.

OBJECTIVE: The Thrombolysis in Myocardial Infarction (TIMI) score is a validated tool for risk stratification of acute coronary syndrome. We hypothesized that the TIMI risk score would be able to risk stratify patients in observation unit for acute coronary syndrome. STUDY DESIGN: Retrospective cohort study of consecutive adult patients placed in an urban academic hospital emergency department observation unit with an average annual census of 65,000 between 2004 and 2007. Exclusion criteria included elevated initial cardiac biomarkers, ST segment changes on ECG, unstable vital signs, or unstable arrhythmias. A composite of significant coronary artery disease (CAD) indicators, including diagnosis of myocardial infarction, percutaneous coronary intervention, coronary artery bypass surgery, or death within 30 days and 1 year, were abstracted via chart review and financial record query. The entire cohort was stratified by TIMI risk scores (0-7) and composite event rates with 95% confidence interval were calculated. RESULTS: In total 2228 patients were analyzed. Average age was 54.5 years, 42.0% were male. The overall median TIMI risk score was 1. Eighty (3.6%) patients had 30-day and 119 (5.3%) had 1-year CAD indicators. There was a trend toward increasing rate of composite CAD indicators at 30 days and 1 year with increasing TIMI score, ranging from a 1.2% event rate at 30 days and 1.9% at 1 year for TIMI score of 0 and 12.5% at 30 days and 21.4% at 1 year for TIMI ≥ 4. CONCLUSIONS: In an observation unit cohort, the TIMI risk score is able to risk stratify patients into low-, moderate-, and high-risk groups.

Transient detection of Chlamydial-specific Th1 memory cells in the peripheral circulation of women with history of Chlamydia trachomatis genital tract infection.

PROBLEM: Development of safe and effective Chlamydia trachomatis vaccines requires better understanding of the host immune responses elicited by natural infection. METHOD OF STUDY: Peripheral blood mononuclear cells isolated from women with or without history of genital tract chlamydial infection were stimulated with inactivated C. trachomatis elementary bodies (EB) in ELISPOT assays that enumerated frequencies of cells producing interferon (IFN)-γ or interleukin (IL)-17. RESULTS: IFN-γ-positive cells were highest among women sampled 30-60 days after diagnosis of C. trachomatis infection and treatment initiation, while the numbers of IFN-γ-positive cells were equally low among uninfected women and women sampled <30 or >60 days after diagnosis of infection. Conversely, IL-17-positive cell numbers were uniformly low among all participants. CONCLUSION: Dramatically reduced numbers of Chlamydia-specific Th1 memory cells in the peripheral circulation of study participants sampled more than 2 months after diagnosis, and initiation of treatment provides new insight into the results from C. trachomatis vaccine trials, in which immunization with EB provided only short-lived protection. Our results also suggest that an effective vaccine against this weakly antigenic intracellular pathogen will need to generate immunological memory more durable than that elicited by natural infection.

Chlamydia trachomatis infection control programs: lessons learned and implications for vaccine development.

Chlamydia trachomatis control efforts that enhance detection and treatment of infected women may paradoxically increase susceptibility of the population to infection. Conversely, these surveillance programs lower incidences of adverse sequelae elicited by genital tract infection (e.g., pelvic inflammatory disease and ectopic pregnancy), suggesting enhanced identification and eradication of C. trachomatis simultaneously reduces pathogen-induced upper genital tract damage and abrogates formation of protective immune responses. In this paper, we detail findings from C. trachomatis infection control programs that increase our understanding of chlamydial immunoepidemiology and discuss their implications for prophylactic vaccine design.