Outpatient myeloablative allo-SCT: a comprehensive approach yields decreased hospital utilization and low TRM.

Historically, myeloablative allogeneic hematopoietic SCT (HSCT) has required prolonged in-patient hospitalization due to the effects of mucosal toxicity and prolonged cytopenias. We explored the safety and feasibility of outpatient management of these patients. A total of 100 consecutive patients underwent a matched-related donor myeloablative allogeneic HSCT for a hematologic malignancy at a single institution. Patients were hospitalized briefly for stem-cell infusion and thereafter only for complications more safely managed in the in-patient setting. The median hospital length of stay from the start of the preparative regimen to day +30 and day +100 post-transplant was 12 and 15 days, respectively. Planned hospital discharge occurred in 79 patients after stem cell infusion. Patients were readmitted to hospital at median of day +7 post transplant, with neutropenic fever being the primary cause for readmission. In total, 18 patients required no in-patient care in the first 100 days. Non-relapse mortality at day 100 and 6 months was 10 and 15%, respectively, for all patients, and 0 and 5%, respectively, for standard risk patients. In summary, outpatient myeloablative allogeneic HSCT with expectant in-patient management can be accomplished safely with low treatment-related morbidity and mortality. Clinical outcomes seem comparable to those reported for traditional in-patient management.

Traditional birth attendant training for improving health behaviours and pregnancy outcomes.

BACKGROUND: Between the 1970s and 1990s, the World Health Organization promoted traditional birth attendant (TBA) training as one strategy to reduce maternal and neonatal mortality. To date, evidence in support of TBA training remains limited and conflicting. OBJECTIVES: To assess effects of TBA training on health behaviours and pregnancy outcomes. SEARCH STRATEGY: We searched the Trials Registers of the Cochrane Pregnancy and Childbirth Group and Cochrane Effective Practice and Organisation of Care Group (EPOC) (June 2006); electronic databases representing fields of education, social, and health sciences (inception to June 2006); the internet; and contacted experts. SELECTION CRITERIA: Published and unpublished randomized controlled trials (RCT), controlled before/after and interrupted time series studies comparing trained and untrained TBAs or women cared for/living in areas served by TBAs. DATA COLLECTION AND ANALYSIS: Three authors independently assessed study quality and extracted data. MAIN RESULTS: Four studies, involving over 2000 TBAs and nearly 27,000 women, are included. One cluster-randomized trial found significantly lower rates in the intervention group regarding stillbirths (adjusted OR 0.69, 95% confidence interval (CI) 0.57 to 0.83, P < 0.001), perinatal death rate (adjusted OR 0.70, 95% CI 0.59 to 0.83, P < 0.001) and neonatal death rate (adjusted OR 0.71, 95% CI 0.61 to 0.82, P < 0.001). Maternal death rate was lower but not significant (adjusted OR 0.74, 95% CI 0.45 to 1.22, P = 0.24) while referral rates were significantly higher (adjusted OR 1.50, 95% CI 1.18 to 1.90, P < 0.001). A controlled before/after study among women who were referred to a health service found perinatal deaths decreased in both intervention and control groups with no significant difference between groups (OR 1.02, 95% CI 0.59 to 1.76, P = 0.95). Similarly, the mean number of monthly referrals did not differ between groups (P = 0.321). One RCT found a significant difference in advice about introduction of complementary foods (OR 2.07, 95% CI 1.10 to 3.90, P = 0.02) but no significant difference for immediate feeding of colostrum (OR 1.37, 95% CI 0.62 to 3.03, P = 0.44). Another RCT found no significant differences in frequency of postpartum haemorrhage (OR 0.94, 95% CI 0.76 to 1.17, P = 0.60) among women cared for by trained versus TBAs. AUTHORS' CONCLUSIONS: The potential of TBA training to reduce peri-neonatal mortality is promising when combined with improved health services. However, the number of studies meeting the inclusion criteria is insufficient to provide the evidence base needed to establish training effectiveness.