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Nanoparticles are a class of newly emerging environmental pollutions. To date, few experiments have been conducted to investigate the effect nanoparticles may have on plant growth and development. It is important to study the effects nanoparticles have on plants because they are stationary organisms that cannot move away from environmental stresses like animals can, therefore they must overcome these stresses by molecular routes such as altering gene expression. microRNAs (miRNA) are a newly discovered, endogenous class of post-transcriptional gene regulators that function to alter gene expression by either targeting mRNAs for degradation or inhibiting mRNAs translating into proteins. miRNAs have been shown to mediate abiotic stress responses such as drought and salinity in plants by altering gene expression, however no study has been performed on the effect of nanoparticles on the miRNA expression profile; therefore our aim in this study was to classify if certain miRNAs play a role in plant response to Al(2)O(3) nanoparticle stress. In this study, we exposed tobacco (Nicotiana tabacum) plants (an important cash crop as well as a model organism) to 0%, 0.1%, 0.5%, and 1% Al(2)O(3) nanoparticles and found that as exposure to the nanoparticles increased, the average root length, the average biomass, and the leaf count of the seedlings significantly decreased. We also found that miR395, miR397, miR398, and miR399 showed an extreme increase in expression during exposure to 1% Al(2)O(3) nanoparticles as compared to the other treatments and the control, therefore these miRNAs may play a key role in mediating plant stress responses to nanoparticle stress in the environment. The results of this study show that Al(2)O(3) nanoparticles have a negative effect on the growth and development of tobacco seedlings and that miRNAs may play a role in the ability of plants to withstand stress to Al(2)O(3) nanoparticles in the environment.

Background The Lives Saved Tool (LiST) estimates the effects of maternal and child health interventions on mortality rates and the number of deaths. The family planning module in Spectrum interacts with LiST by providing estimates of the effects of scaling up family planning use on the number of live births, miscarriages, abortions, and stillbirths. Methods We use the proximate determinants of fertility framework to estimate the effects of changes in contraceptive use, proportion married, postpartum insusceptibility, abortion and sterility on the total fertility rate. We extend this framework to estimate the number of intended and unintended pregnancies and the resulting live births, abortions, stillbirths, and miscarriages. Results We apply the model to four countries (Mali, Kenya, Indonesia, and Ukraine) to demonstrate possible trends with a range of family planning and fertility levels. In high-fertility countries, such as Mali, increases in contraceptive use will partially compensate for the increasing number of women of reproductive age to reduce the annual increases in pregnancies and births. Most unintended pregnancies occur to women defined as having unmet need for contraception. In low-fertility countries, increases in contraceptive use may reduce abortion rates and low levels of unmet need mean that most unintended pregnancies are due to method failure. Conclusions The family planning module in Spectrum provides a useful framework to incorporate changes in contraceptive practices and pregnancy outcomes in the LiST calculations of mortality rates and deaths.

With recent results showing a global decline in overall maternal mortality during the last two decades and with the target date for achieving the Millennium Development Goals only four years away, the question of how to continue or even accelerate the decline has become more pressing. By knowing where the risk is highest as well as where the numbers of deaths are greatest, it may be possible to re-direct resources and fine-tune strategies for greater effectiveness in efforts to reduce maternal mortality. We aggregate data from 38 Demographic and Health Surveys that included a maternal mortality module and were conducted in 2000 or later to produce maternal mortality ratios, rates, and numbers of deaths by five year age groups, separately by residence, region, and overall mortality level. The age pattern of maternal mortality is broadly similar across regions, type of place of residence, and overall level of maternal mortality. A \"J\" shaped curve, with markedly higher risk after age 30, is evident in all groups. We find that the excess risk among adolescents is of a much lower magnitude than is generally assumed. The oldest age groups appear to be especially resistant to change. We also find evidence of extremely elevated risk among older mothers in countries with high levels of HIV prevalence. The largest number of deaths occurs in the age groups from 20-34, largely because those are the ages at which women are most likely to give birth so efforts directed at this group would most effectively reduce the number of deaths. Yet equity considerations suggest that efforts also be directed toward those most at risk, i.e., older women and adolescents. Because women are at risk each time they become pregnant, fulfilling the substantial unmet need for contraception is a cross-cutting strategy that can address both effectiveness and equity concerns.

Background Choosing an optimum set of child health interventions for maximum mortality impact is important within resource poor policy environments. The Lives Saved Tool (LiST) is a computer model that estimates the mortality and stillbirth impact of scaling up proven maternal and child health interventions. This paper will describe the methods used to estimate the impact of scaling up interventions on neonatal and child mortality. Model structure and assumptions LiST estimates mortality impact via five age bands 0 months, 1-5 months, 6-11 months, 12-23 months and 24 to 59 months. For each of these age bands reductions in cause specific mortality are estimated. Nutrition interventions can impact either nutritional statuses or directly impact mortality. In the former case, LiST acts as a cohort model where current nutritional statuses such as stunting impact the probability of stunting as the cohort ages. LiST links with a demographic projections model (DemProj) to estimate the deaths and deaths averted due to the reductions in mortality rates. Using LiST LiST can be downloaded at http://www.jhsph.edu/dept/ih/IIP/list/ where simple instructions are available for installation. LiST includes default values for coverage and effectiveness for many less developed countries obtained from credible sources. Conclusions The development of LiST is a continuing process. Via technical inputs from the Child Health Epidemiological Group, effectiveness values are updated, interventions are adopted and new features added.

SDG 5.3 targets include eliminating harmful practices such as Female Genital Mutilation (FGM). Limited information is available about levels of investment needed and realistic estimates of potential incidence change. In this work, we estimate the cost and impact of FGM programs in 31 high burden countries. This analysis combines program data, secondary data analysis, and population-level costing methods to estimate cost and impact of high and moderate scaleup of FGM programs between 2020 and 2030. Cost per person or community reached was multiplied by populations to estimate costs, and regression analysis was used to estimate new incidence rates, which were applied to populations to estimate cases averted. Reaching the high-coverage targets for 31 countries by 2030 would require an investment of US$ 3.3 billion. This scenario would avert more than 24 million cases of FGM, at an average cost of US$ 134 per case averted. A moderate-coverage scenario would cost US$ 1.6 billion and avert more than 12 million cases of FGM. However, average cost per case averted hides substantial variation based on country dynamics. The most cost-effective investment would be in countries with limited historic change in FGM incidence, with the average cost per case averted between US$ 3 and US$ 90. The next most effective would be those with high approval for FGM, but a preexisting trend downward, where cost per case averted is estimated at around US$ 240. This analysis shows that although data on FGM is limited, we can draw useful findings from population-level surveys and program data to guide resource mobilization and program planning.

Background Achieving the Sustainable Development Goals will require careful allocation of resources in order to achieve the highest impact. The Lives Saved Tool (LiST) has been used widely to calculate the impact of maternal, neonatal and child health (MNCH) interventions for program planning and multi-country estimation in several Lancet Series commissions. As use of the LiST model increases, many have expressed a desire to cost interventions within the model, in order to support budgeting and prioritization of interventions by countries. A limited LiST costing module was introduced several years ago, but with gaps in cost types. Updates to inputs have now been added to make the module fully functional for a range of uses. Methods This paper builds on previous work that developed an initial version of the LiST costing module to provide costs for MNCH interventions using an ingredients-based costing approach. Here, we update in 2016 the previous econometric estimates from 2013 with newly-available data and also include above-facility level costs such as program management. The updated econometric estimates inform percentages of intervention-level costs for some direct costs and indirect costs. These estimates add to existing values for direct cost requirements for items such as drugs and supplies and required provider time which were already available in LiST Costing. Results Results generated by the LiST costing module include costs for each intervention, as well as disaggregated costs by intervention including drug and supply costs, labor costs, other recurrent costs, capital costs, and above-service delivery costs. These results can be combined with mortality estimates to support prioritization of interventions by countries. Conclusions The LiST costing module provides an option for countries to identify resource requirements for scaling up a maternal, neonatal, and child health program, and to examine the financial impact of different resource allocation strategies. It can be a useful tool for countries as they seek to identify the best investments for scarce resources. The purpose of the LiST model is to provide a tool to make resource allocation decisions in a strategic planning process through prioritizing interventions based on resulting impact on maternal and child mortality and morbidity.

Background: Despite a wide range of contraceptive methods, unmet need persists. New contraceptive technologies (CTs) have the potential to improve uptake and continuation. CT development has a long-time horizon; products will be introduced into markets that look very different than today. Identifying viable investments requires an understanding of these future markets. For this work the 2040 potential contraceptive market is described utilizing seven market segments based on marital status, fertility preferences, and patterns of sexual activity outside of marriage.  Methods: Market size estimates are developed by country for all countries in the world for a current market (2020) and a future market (2040). United Nation’s (UN) population projections of the number of women of reproductive age (WRA) form the basis of this work. WRA are then segmented into market segments based on marital status, fertility intentions, and patterns of sexual activity outside of marriage.  Each segment is further subdivided by contraceptive use versus non-use.  Segmentation draws from UN projections, household surveys, census data, and modeling techniques developed for this work. Results: The largest market increases will be seen in Africa; most notably among the segment of married women wanting no more children. By contrast, Asia will see declines across all three married segments, coupled with increases among sexually active unmarried segments.  Levels of contraceptive use are projected to vary widely by segment, with differential patters across regions. Conclusions: This analysis projects the impact of demographic changes, evolving fertility preferences, shifts in sexual activity outside of marriage and increased utilization of contraceptives in shaping the contraceptive market of 2040. Results show that there is not one global market, but distinct markets that vary in size and shape across the world. This diversity suggests that a range of different new CTs could have potential for uptake.

Background/objectivesHeart failure (HF) is a growing clinical and economic burden for patients and health systems. The COVID-19 pandemic has led to avoidance and delay in care, resulting in increased morbidity and mortality among many patients with HF. The increasing burden of HF during the COVID-19 pandemic led us to evaluate the quality and safety of the Hospital at Home (HAH) for patients presenting to their community providers or emergency department (ED) with symptoms of acute on chronic HF (CHF) requiring admission.Design/outcomesA non-randomised prospective case–controlled of patients enrolled in the HAH versus admission to the hospital (usual care, UC). Primary outcomes included length of stay (LOS), adverse events, discharge disposition and patient satisfaction. Secondary outcomes included 30-day readmission rates, 30-day ED usage and ED dwell time.ResultsSixty patients met inclusion/exclusion criteria and were included in the study. Of the 60 patients, 40 were in the HAH and 20 were in the UC group. Primary outcomes demonstrated that HAH patients had slightly longer LOS (6.3 days vs 4.7 days); however, fewer adverse events (12.5% vs 35%) compared with the UC group. Those enrolled in the HAH programme were less likely to be discharged with postacute services (skilled nursing facility or home health). HAH was associated with increased patient satisfaction compared with Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score in North Carolina. Secondary outcomes of 30-day readmission and ED usage were similar between HAH and UC.ConclusionsThe HAH pilot programme was shown to be a safe and effective alternative to hospitalisation for the appropriately selected patient presenting with acute on CHF.

The first 12 months following childbirth are a period when a subsequent pregnancy holds the greatest risk for mother and baby, but also when there are numerous contacts with the healthcare system for postnatal care for mother and baby (immunisation, nutrition, etc.). The benefits and importance of postpartum family planning are well documented. They include a reduction in risk of miscarriage, as well as mitigation of (or protection against) low birth weight, neonatal and maternal death, preterm birth, and anaemia. The objectives of this paper are to assess patterns and trends in the use of postpartum family planning at the country level, to determine whether postpartum family planning is associated with birth interval and parity, and to identify the health services most closely associated with postpartum family planning after adjusting for socio-economic characteristics. Data were used from Demographic and Health Surveys that contain a reproductive calendar, carried out within the last 10 years, from Ethiopia, Malawi, and Nigeria. All women for whom the calendar was completed and who gave birth between 57 and 60 months prior to data collection were included in the analysis. For each of the births, we merged the reproductive calendar with the birth record into a survey for each country reflecting the previous 60 months. The definition of the postpartum period in this paper is based on a period of 3 months postpartum. We used this definition to assess early adoption of postpartum family planning. We assessed variations in postpartum family planning according to demographic and socio-economic variables, as well as its association with various contact opportunities with the health system [antenatal care (ANC), childbirth in facilities, immunisation, etc.]. We did simple descriptive analysis with tabular, graphic, and 'equiplot' displays and a logistic regression controlling for important background characteristics. Overall, variation in postpartum use of modern contraception was not affected over the years by age or marital status. One contrast to this is in Ethiopia, where the data show a significant increase in uptake of postpartum contraception among adolescents from 2005 to 2011. There are systematic and pervasive equity issues in the use of modern postpartum family planning by education level, place of residence, and wealth quintile, especially in Ethiopia where the gaps are very large. Disaggregation of data also point to significant sub-national variations. After adjusting for socio-economic variables, the most consistent health sector services associated with modern postpartum contraception are institutional childbirth and child immunisation. ANC is less likely to be associated with the use of modern postpartum family planning. Postpartum use of modern family planning has remained very low over the years, including for childbearing adolescents. Our results indicate that improving postpartum family planning requires policies and strategies to address the inequalities caused by socio-economic factors and the integration of family planning with maternal and newborn health services, particularly with childbirth in facilities and child immunisation. Scaling up systematic screening, training of providers, and generation of demand are some possible ways forward.

Background In malaria-endemic countries, malaria prevention and treatment are critical for child health. In the context of intervention scale-up and rapid changes in endemicity, projections of intervention impact and optimized program scale-up strategies need to take into account the consequent dynamics of transmission and immunity. Methods The new Spectrum-Malaria program planning tool was used to project health impacts of Insecticide-Treated mosquito Nets (ITNs) and effective management of uncomplicated malaria cases (CMU), among other interventions, on malaria infection prevalence, case incidence and mortality in children 0–4 years, 5–14 years of age and adults. Spectrum-Malaria uses statistical models fitted to simulations of the dynamic effects of increasing intervention coverage on these burdens as a function of baseline malaria endemicity, seasonality in transmission and malaria intervention coverage levels (estimated for years 2000 to 2015 by the World Health Organization and Malaria Atlas Project). Spectrum-Malaria projections of proportional reductions in under-five malaria mortality were compared with those of the Lives Saved Tool (LiST) for the Democratic Republic of the Congo and Zambia, for given (standardized) scenarios of ITN and/or CMU scale-up over 2016–2030. Results Proportional mortality reductions over the first two years following scale-up of ITNs from near-zero baselines to moderately higher coverages align well between LiST and Spectrum-Malaria —as expected since both models were fitted to cluster-randomized ITN trials in moderate-to-high-endemic settings with 2-year durations. For further scale-up from moderately high ITN coverage to near-universal coverage (as currently relevant for strategic planning for many countries), Spectrum-Malaria predicts smaller additional ITN impacts than LiST, reflecting progressive saturation. For CMU, especially in the longer term (over 2022–2030) and for lower-endemic settings (like Zambia), Spectrum-Malaria projects larger proportional impacts, reflecting onward dynamic effects not fully captured by LiST. Conclusions Spectrum-Malaria complements LiST by extending the scope of malaria interventions, program packages and health outcomes that can be evaluated for policy making and strategic planning within and beyond the perspective of child survival.