A matched case-control study of risk factors for neonatal tetanus in Karachi, Pakistan

BACKGROUND

Previous studies have identified various risk factors for neonatal tetanus (NNT) in rural areas of Pakistan. The present matched case control study was conducted to further evaluate these risk factors in an urban setting.

AIM

The study was carried out to identify risk factors for NNT in Karachi.

MATERIALS AND METHODS

Patients of NNT (n = 125) diagnosed from January 1998 to February 2001 were recruited through a surveillance system of Expanded Programme on Immunization (EPI). Two neighbourhood controls (n = 250) were matched for each case for gender and date of birth of the case.

STATISTICAL ANALYSIS

Conditional logistic regression was performed to assess the independent effect of factors associated with NNT.

RESULTS

The final multivariable model identified subsequent application of substances on the umbilical cord (adjusted matched odds ratio [adj. mOR] = 5.1 [2.7-9.7]), home delivery (adj. mOR = 1.8; 95% CI: 1.1- 3.1) and illiterate mother (adj. mOR = 1.6; 95% CI: 1.0- 2.0) as risk factors for NNT after adjusting for other variables in the model. Population attributable risk per cent (PAR %) for subsequent cord application was 69% and PAR % for home delivery was 31%.

CONCLUSION

Health planners, while formulating control strategies through immunization programmes should also take into account the impact of post-delivery practices, such as 'subsequent cord application' along with pre-delivery practices. Health awareness regarding appropriate post-delivery practices should be promoted and counselling of pregnant women for giving preference to health care setting for delivery is also crucial.

Cellular neurothekeoma in the arm of a child

Soft tissue tumours of the limb in children are uncommon. We report a cellular neurothekeoma, which presented as a hard, irregular tumour in the upper arm of a 7-year-old child. The differential diagnosis of soft tissue tumours in the upper limbs of children is discussed.

Clinical and ultrastructural findings in mare's tail lines of the corneal epithelium

AIMS

Mare's tail lines are uncommon, grey, parallel, tapering epithelial lines, which may give rise to discomfort or to visual symptoms. The authors report the clinical and ultrastructural findings in two patients

METHODS

Therapeutic debridement was performed in two patients suffering from mare's tail disorder. The loosely attached epithelium was removed and fixed in glutaraldehyde containing cuprolinic blue and processed in a standard fashion for electron microscopy.

RESULTS

Ultrastructural studies showed an avascular, collagenous pannus extending under the whole of the excised epithelium in each case and separated from it by a thickened basal lamina like zone. The basal laminar material extended into the epithelium in folds, in keeping with the clinical features. Interesting ultrastructural features included: (1) a lack of hemidesmosomes in relation to the basal laminar material; (2) trapping of degenerate keratocytes within the invaginating basal laminar folds; (3) an unusual regularity and fine dimensions of the collagen fibrils and proteoglycans making up the subepithelial pannus. The basal laminar material contained proteoglycans and small fibres similar in appearance to long spacing collagen.

CONCLUSIONS

Mare's tail lines are caused by basal laminar material, assumed to be chiefly of epithelial origin, which invaginates the corneal epithelium. The presence of occasional keratocytes within the invaginating folds suggests that there may be a stromal contribution to the disorder. The visibility of mare's tail lines in the focal beam of the slit lamp is likely to be related to the thickness and light scattering properties of the invaginations and of the subepithelial deposits. Tractional forces, imposed by lid action, could explain their horizontal disposition.

The effect of intracalyceal distribution on the clearance of renal stones of ≥ 20 mm in children after extracorporeal lithotripsy

OBJECTIVES

To determine the effect of the intracalyceal distribution of renal stones on clearance rates after treating paediatric nephrolithiasis with extracorporeal shock wave lithotripsy (ESWL).

PATIENTS AND METHODS

We assessed a retrospective case series of children (aged < or = 14 years) undergoing lithotripsy on an MPL 9000 (Dornier GmbH, Germany) echo-guided lithotripter. Patients were identified using an international coding and indexing system and ESWL registry. In all, 125 children were treated during 1990-2003, but 21 had stones of > or = 20 mm. Stone clearance was assessed at 1 and 3 months, the stone-free state being defined as no radiological evidence of stone or fragments of < or = 3 mm. Failed treatments were analysed to identify any correlation with stone site.

RESULTS

The overall stone-free rate was 81%; in four children the treatment failed (all girls) and subsequently they required ancillary procedures. Nineteen patients (90%) received up to three sessions of ESWL; two required four or more sessions. Of the four children in whom treatment failed, two had JJ stents; the stones were in the lower pole calyx in two, and the renal pelvis and lower pole calyx in two. The mean stone size in those where treatment failed was 25 mm, vs 21 mm in the stone-free group. The complication rate was 19%, but only one child required admission to hospital.

CONCLUSIONS

ESWL is very effective for renal stones in children, with minimal morbidity. Lower pole and partial staghorn stones with a major component in the lower pole calyx should preferably be treated by a percutaneous approach.

Cellular uptake and intracellular fate of antisense oligonucleotides

Antisense oligonucleotides with sequences complementary to a given genetic target can enter cells in sufficient quantities to selectively inhibit gene expression. Thus, they have a potential therapeutic use in preventing undesirable gene expression in diseases such as cancer and AIDS. However, it is remarkable that these molecules, which have high molecular weights and are often charged, gain entry to cells at all. In this article, we review the possible mechanisms by which oligonucleotides enter cells and their subsequent intracellular fates. We also discuss current approaches for improving cellular uptake and delivery of antisense nucleic acids to their intended targets.

Animal disease surveillance: prospects for development in Pakistan

Surveillance is a continuous and systematic process of collection, consolidation, analysis, interpretation and dissemination of relevant information on the occurrence of health problems. Data from surveillance can be used to calculate the incidence and prevalence of events, to categorise disease distribution by relevant characteristics, to guide investigations into the occurrence of epidemic and endemic disease, and to contribute essential information for the design and evaluation of effective disease prevention and control programmes. Disease surveillance systems should also respond to the information needs of government agencies, agribusiness, academia, producers and consumers. However, in most developing countries, including Pakistan, animal disease surveillance systems are not well developed, and do not produce a desirable quality of information on disease status and trends. In this paper, the authors describe various facets of a generic surveillance system and propose a structure for a surveillance system at district level. Such systems have been designed and implemented for public health surveillance in a number of countries, and may be developed to meet the needs of veterinary public health.

The cost-effectiveness of health education in improving knowledge and awareness about intestinal parasites in rural Bangladesh

The impact of regular health education in improving knowledge, attitude and practices in the control of intestinal parasites was examined in four rural areas of Bangladesh; two areas received health education and the other two areas were controls. By the end of the 18-month study households receiving health education showed highly significant improvements in knowledge, water and sanitation facilities and personal hygiene compared with households in the control areas. Improving knowledge by 1% cost between US dollars 0.75 and 0.82 per household, while a 1% improvement in personal hygiene cost between US dollars 1.10 and 1.32 per household and water and sanitation between US dollars 1.39 and 1.52 per household.

Recurrent Wilms tumour presenting as bilateral pneumothoraces

We report the case of a 14-year-old girl who presented with bilateral pneumothoraces secondary to recurrent Wilms' tumour, 10 years following the initial treatment of her tumour. Recurrent Wilms' tumour presenting as bilateral pneumothorax so long after the original diagnosis has not previously been reported.

Injections in health care settings: a risk factor for acute hepatitis B virus infection in Karachi, Pakistan

A case control study was conducted to identify the association of therapeutic injections with acute hepatitis B virus (HBV) infection in Karachi, Pakistan. We enrolled 67 cases of acute HBV infection (IgM anti-HBc positive) and 247 controls (anti-HBc negative) from four hospitals of Karachi during July 2000-June 2001. Exposure to various risk factors during the period relevant to the incubation period of HBV was recorded both from cases and controls using a structured questionnaire. Multivariate logistic regression analysis of the data showed that cases were more likely to have received one injection (OR = 4.0; 95 % CI 1.4, 11.1), or more than one injection (OR = 6.3; 95 % CI 3.2, 12.4) compared to controls. The estimated population attributable risk (PAR) for therapeutic injections was 53%. Also the cases compared to controls were more likely to have household size of seven or more (OR = 1.9; 95 % CI 0.95, 3.9). This study showed that unsafe therapeutic injections appear to be the major risk factor for acute HBV infection and needs immediate focus from public health stand point.

Inhibition of calcium/calmodulin-dependent protein kinase II normalizes diabetes-induced abnormal vascular reactivity in the rat perfused mesenteric vascular bed

1. Calcium/calmodulin-dependent protein kinase II (CaMKII) has an important function in mediating insulin release but its role in the development of diabetes-induced cardiovascular complications is not known. 2. We investigated the ability of a chronic administration of KN-93 (5 mg kg(-1) alt diem for 4 weeks), an inhibitor of CaMKII, to modulate the altered vasoreactivity of the perfused mesenteric bed to common vasoconstrictors and vasodilators in streptozotocin (STZ)-induced diabetes. 3. The vasoconstrictor responses induced by noradrenaline (NE), endothelin-1 (ET-1), and angiotensin II (Ang II), were significantly increased whereas, vasodilator responses to carbachol and histamine were significantly reduced in the perfused mesenteric bed of the STZ-diabetic rats as compared with non-diabetic controls. 4. Inhibition of CaMKII by KN-93 treatment did not affect blood glucose levels but produced a significant normalization of the altered agonist-induced vasoconstrictor and vasodilator responses. KN-93 did not affect agonist-induced responses in control animals. In addition, KN-93 significantly reduced weight loss in diabetic rats. 5. The present data suggest that CaMKII is an essential mediator in the development of diabetic vascular dysfunction and may also play an important role in signalling pathways leading to weight loss during diabetes.

Risk behaviours associated with urethritis and genital ulcer disease in prison inmates, Sindh, Pakistan

We evaluated the epidemiological differences with respect to demographics, drug use and sexual behaviours associated with lifetime risk of urethritis, genital ulcer disease [GUD] and urethritis and GUD together among 3395 male prisoners in Sindh. Factors associated with urethritis and GUD alone were sex with multiple females, sex with men, and ethnicity. Additional factors associated with urethritis alone were sex with prostitutes, sex with partners having multiple partners and sex with partners believed to be injecting drugs. Behaviours associated with lifetime risk for urethritis and GUD together were sex with multiple females, sex with prostitutes, sex with men, sex with partners believed to be injecting drugs and ethnicity. These relationships were consistently stronger compared to urethritis or GUD alone.

Randomised controlled trial of cognitive-behavioural therapy in early schizophrenia: acute-phase outcomes

BACKGROUND

Cognitive-behavioural therapy (CBT) improves persistent psychotic symptoms.

AIMS

To test the effectiveness of added CBT in accelerating remission from acute psychotic symptoms in early schizophrenia.

METHOD

A 5-week CBT programme plus routine care was compared with supportive counselling plus routine care and routine care alone in a multi-centre trial randomising 315 people with DSM-IV schizophrenia and related disorders in their first (83%) or second acute admission. Outcome assessments were blinded.

RESULTS

Linear regression over 70 days showed predicted trends towards faster improvement in the CBT group. Uncorrected univariate comparisons showed significant benefits at 4 but not 6 weeks for CBT v. routine care alone on Positive and Negative Syndrome Scale total and positive sub-scale scores and delusion score and benefits v. supportive counselling for auditory hallucinations score.

CONCLUSIONS

CBT shows transient advantages over routine care alone or supportive counselling in speeding remission from acute symptoms in early schizophrenia.

The upside-down intubating laryngeal mask airway: a technique for cases of fixed flexed neck deformity

IMPLICATIONS

When the neck is fixed in extreme flexion, access to the windpipe becomes very difficult. The intubating laryngeal mask airway (ILMA) appears unsuitable for guiding the breathing tube into the windpipe in such cases because of its rigid, preformed shape. However, the ILMA introduced upside down may provide the answer, even if the mouth opening is smaller than normal.

Risk behaviours associated with urethritis and genital ulcer disease in prison inmates, Sindh, Pakistan

We evaluated the epidemiological differences with respect to demographics, drug use and sexual behaviours associated with lifetime risk of urethritis, genital ulcer disease (GUD) and urethritis and GUD together among 3395 male prisoners in Sindh. Factors associated with urethritis and GUD alone were sex with multiple females, sex with men, and ethnicity. Additional factors associated with urethritis alone were sex with prostitutes, sex with partners having multiple partners and sex with partners believed to be injecting drugs. Behaviours associated with lifetime risk for urethritis and GUD together were sex with multiple females, sex with prostitutes, sex with men, sex with partners believed to be injecting drugs and ethnicity. These relationships were consistently stronger compared to urethritis or GUD alone.

Prevalence and risk factors associated with tuberculin skin test positivity among household contacts of smear-positive pulnionary tuberculosis cases in Umerkot, Pakistan

STUDY POPULATION AND SETTING

Household contacts of acid-fast bacilli (AFB) sputum smear-positive tuberculosis patients in the Umerkot Taluka, Sindh, Pakistan.

OBJECTIVE

To estimate the prevalence of and identify risk factors associated with tuberculin skin test (TST) positivity among household contacts of acid-fast bacilli (AFB) sputum smear-positive pulmonary tuberculosis cases.

DESIGN

A cross-sectional study of household contacts of AFB sputum smear-positive tuberculosis cases, registered at the Umerkot Anti-Tuberculosis Association clinic from August 1999 to September 1999. The contact's Mycobacterium tuberculosis infection status was assessed using TST. On the day of the TST, a pre-designed questionnaire was administered to collect data on putative risk factors for TST positivity among contacts. The data were analysed using a marginal logistic regression model by the method of generalised estimating equations (GEE) to determine risk factors independently associated with TST positivity.

RESULTS

The prevalence of TST positivity among household contacts of AFB sputum smear-positive index patients was 49.4%. The final multivariate GEE model showed that contact's age and sleeping site relative to the index case, the intensity of the index case's AFB sputum-smear positivity and the contact's BCG scar status were independent predictors of TST positivity among household contacts of AFB sputum smear-positive index cases.

CONCLUSIONS

The results suggest that the household contacts of AFB sputum smear-positive tuberculosis patients in a poor neighbourhood of rural Sindh had a high prevalence of M. tuberculosis infection as determined by TST. Poor housing conditions seem to contribute to the spread of M. tuberculosis infection. Early diagnosis of pulmonary TB through evaluation of TST-positive household contacts, followed by appropriate therapy, may prevent further spread of M. tuberculosis infection. We recommend an awareness programme to prevent household contacts from acquiring M. tuberculosis infection from smear-positive pulmonary TB cases.

Prevalence and risk factors for intrafamilial transmission of hepatitis C virus in Karachi, Pakistan

Household contacts of hepatitis C virus (HCV)-positive patients are considered at increased risk of HCV infection. This cross-sectional study during April through June 1999 assessed the prevalence and risk behaviours associated with HCV seropositivity among the household contacts of HCV seropositive thalassaemic children in Karachi, Pakistan. Among the 341 household contacts of 86 thalassaemic HCV seropositive children who were tested, 70 (20.5%) were positive for anti-HCV antibodies. The stratified analysis showed that HCV seroprevalence among the contacts did not differ significantly by the gender of the index patient and the type of relationship of contact with the index patient. However, HCV seroprevalences among the fathers and mothers of male index patients was substantially higher compared to those of female index patients. HCV RNA was recovered and genotyped from nine index patients and corresponding nine HCV-seropositive household contacts. HCV genotype 3a and 3b were found in 89% (8/9) and 11% (1/9) of the pairs, respectively. The final multivariable conditional logistic regression model revealed that after adjusting for the effect of ethnicity and past hospital admission history, the HCV-seropositive household contacts were more likely than HCV seronegative household contacts to have been bitten by the carrier [adjusted matched odds ratio (mOR)=2.6, 95% CI 1.3-5.2] or have shared a toothbrush with the carrier (adjusted mOR=8.2; 95% CI 1.56-43.5). Control efforts should focus on the risk behaviours.

Chronic eosinophilic pneumonia associated with T-cell lymphoma

A case of a woman presenting with a parotid swelling is described. She had chronic eosinophilic pneumonia (CEP) for approximately 2 years prior to presentation. After further investigation she had biopsy of her parotid, which proved to be T-cell lymphoma. This is a rare association, the diagnosis and the management of this condition is discussed.

Lipoic acid increases glucose uptake by skeletal muscles of obese-diabetic ob/ob mice

AIM

Alpha-lipoic acid has been reported to increase glucose disposal in diabetic states. This study has examined the effect of alpha-lipoic acid on glucose uptake by cultured L6 muscle cells and different types of skeletal muscles in normal lean (+/+) and severely insulin-resistant, obese-diabetic (ob/ob) mice.

METHODS

Glucose uptake was measured in L6 muscle cells using the non-metabolized glucose analogue 2-deoxy-d-glucose (2DG), and in isolated muscles by glucose disappearance from the incubation medium.

RESULTS

In L6 muscle cells, short-term incubations (2-12 h) with 10(-3) m alpha-lipoic acid increased glucose uptake by 40-80%, approximately the same extent as 10(-6) m insulin. Combination of the two agents produced a slightly greater increase (120% at 12 h) than either alone. Red quadriceps (mainly type 1 fibres), diaphragm (similar proportions of type 1 and 2 fibres) and abdominal muscle (mainly type 2 fibres) from normal mice incubated with 10(-3) m alpha-lipoic acid showed increased glucose uptake to a similar extent as 10(-6) m insulin in each of the three muscles. Muscles from ob/ob mice, which showed little response to insulin, showed a substantial increase (approximately 300%, p < 0.05-0.01) in glucose uptake when 10(-3) m alpha-lipoic acid was added in the presence of insulin. The alpha-lipoic acid also increased glucose uptake in red quadriceps (approximately 300%, p < 0.01) from ob/ob mice without added insulin.

CONCLUSION

The results suggest that alpha-lipoic acid can increase glucose uptake by a range of normal muscle types and improve the response to insulin by insulin-resistant skeletal muscles of ob/ob mice.

Episodic ataxia type-1 mutations in the Kv1.1 potassium channel display distinct folding and intracellular trafficking properties

Episodic ataxia type 1 (EA-1) is a neurological disorder arising from mutations in the Kv1.1 potassium channel alpha-subunit. EA-1 patients exhibit substantial phenotypic variability resulting from at least 14 distinct EA-1 point mutations. We found that EA-1 missense mutations generate mutant Kv1.1 subunits with folding and intracellular trafficking properties indistinguishable from wild-type Kv1.1. However, the single identified EA-1 nonsense mutation exhibits intracellular aggregation and detergent insolubility. This phenotype can be transferred to co-assembled Kv1 alpha- and Kv beta-subunits associated with Kv1.1 in neurons. These results suggest that as in many neurodegenerative disorders, intracellular aggregation of misfolded Kv1.1-containing channels may contribute to the pathophysiology of EA-1.