The doctor entered the classroom with a stethoscope around her neck, and a purple veil neatly tied over her white coat. There, she watched as her students practised a breech delivery on a plastic doll. “Careful with the neck”, she said, as a student wiggled a baby doll out, legs first. The women in the classroom were midwifery students, there to learn how to save lives in the impoverished Afghan countryside, where death is ever present, even as life begins.
Claudia Heidegger and colleagues report (Feb 2, p 385) that the use of supplemental parenteral nutrition (SPN) in patients unable to achieve adequate nutrient intake in the first 3 days of intensive-care unit (ICU) stay results in fewer infections between day 9 and day 28 compared with patients who had enteral nutrition only. They compare their study to the EPaNIC trial in which recipients of SPN had a poorer outcome. But Heidegger and colleagues do not discuss the methodological soundness of the EPaNIC trial and the potential biases in their own trial.
Claudia Heidegger and colleagues report the effect of supplemental parenteral nutrition (SPN) administered from day 4 to day 8 after intensive-care unit (ICU) admission to patients already receiving substantial amounts of enteral nutrition. Clinical outcomes were unaffected. Nevertheless, the authors conclusion that less infections occured between day 9 and day 28 provides a rationale to recommend this treatment. This conclusion seems biased.
The study by Claudia Heiddeger and colleagues is of considerable interest to critical–care practitioners. We hope that the authors can clarify some of their findings.
Undernutrition is an important risk factor for infections and poor outcome in the intensive-care unit (ICU). New guidelines recommend the addition of parenteral nutrition to enteral nutrition to supply patients in ICU: parenteral nutrition initiated after 1 week or earlier (after 2–3 days in ICU).
We have serious concerns regarding the interpretation of the results of Claudia Heidegger and colleagues' study. First, we would argue that patients in both study groups received grossly inadequate enteral nutrition. Second, the rate of nosocomial infections (particularly pneumonia) in both study groups is very high. Third, there is no difference in the rate of hospital–acquired pneumonia by day 28 between groups (), contradicting the interpretation of results.
Our study focused on nosocomial infections post intervention (day 9 until day 28), because our hypothesis was that time and energy were required to achieve a metabolic effect with an observable clinical effect. 5-day intervention was chosen because a nutrition intervention before major surgery of such a duration was shown to improve outcome. The decision to change the primary outcome was taken when the activity of the second centre (Lausanne) started with a delay of a few months due to administrative reasons.
We welcome the publication of the manifesto for maternal health post-2015 (Feb 23, p 601). Implementation of the steps outlined in this manifesto would result in substantive improvements in maternal and neonatal health.
The recommendations for maternal health are an excellent framework to build on to improve maternal health.
A note of appreciation to Jim Campbell and colleagues for recognising the error in the manifesto published as a result of the Global Maternal Health Conference held on Jan 15–17, 2013, in Arusha, Tanzania. The Maternal Health Task Force, Management and Development for Health, and The Lancet Editor sincerely regret the omission of midwives in the manifesto. The correction has now been made.
We are concerned that the new overarching Maternal Death Surveillance and Response (MDSR) programme, could have an adverse effect on current and future Maternal Death Reviews (MDRs).
Registration of deaths in England and Wales is not fit for purpose, as the Royal Statistical Society makes clear with ten arguments against late registration, and calls to action by national statisticians, health and social care information centres, and ministers.
The upcoming debate on the proposal for European regulation on clinical trials will have to unravel many knots. In addition to removing any reference to Ethics Committees, the proposal, released by the EU Commission, established ground for a single scientific assessment for the authorisation to conduct a clinical trial. This one-entry evaluation, which will then be valid for all concerned member states, has been artificially dissociated from national ethical assessments. Other deregulation measures were also put forward, introducing provisions that will negatively impact on the protection of trial participants, such as narrowing the definition of a clinical trial.
Road traffic injuries are an emerging public health priority for Iraq that will need to be addressed. Although reliable data on the incidence of road traffic injuries in Iraq are lacking, it is an important public health issue, and information can be derived from indirect indicators.
Langer A, Horton R, Chalamilla G. A manifesto for maternal health post-2015. Lancet 2013; 381: 601–02—In this Comment, the final point of the panel should read: “Finally, we must fulfil all of these actions sustainably, which means universal access to services free at the point of demand within a strong health system—to family planning, to emergency obstetric care, to safe abortion, to properly trained health individuals, especially midwives and those providing midwifery services.” This correction has been made to the online version as of May 17, 2013.
Palmu AA, Jokinen J, Borys D, et al. Effectiveness of the ten-valent pneumococcal Haemophilus influenza protein D conjugate vaccine (PHiD-CV10) against invasive pneumococcal disease: a cluster randomised trial. Lancet 2013; 381: 214–22— The total number of children enrolled was 47 366, not 47 369 (data pertaining to three participants had been entered into the database twice). The results were checked after exclusion of the duplicates; the error did not affect any of the results of the vaccine effectiveness and safety endpoints.
In their insightful Comment on our meta-analysis testing the impact of participatory women's groups on maternal and neonatal mortality, Betty Kirkwood and Rajiv Bahl suggest that including stratified results from the MaiMwana trial might have led to erroneous conclusions. We re-ran the meta-analyses using MaiMwana's factorial results (maternal mortality odds ratio 0·48, 95% CI 0·26–0·91; neonatal mortality 0·85, 0·59–1·22). With all seven trials the results indicate a 34% reduction in maternal mortality (0·66, 95% CI 0·39–0·93), and a 20% reduction in neonatal mortality (0·80, 95% CI 0·68–0·93).
[Articles] Effect of women's groups and volunteer peer counselling on rates of mortality, morbidity, and health behaviours in mothers and children in rural Malawi (MaiMwana): a factorial, cluster-randomised controlled trial
Community mobilisation through women's groups and volunteer peer counsellor health education are methods to improve maternal and child health outcomes in poor rural populations in Africa.
[Articles] Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis
With the participation of at least a third of pregnant women and adequate population coverage, women's groups practising participatory learning and action are a cost-effective strategy to improve maternal and neonatal survival in low-resource settings.