An evaluation of ²²⁶Ra and ²²⁸Ra in drinking water in several counties in Texas, USA

Naturally Occurring Radioactive Material (NORM) or Technology Enhanced Naturally Occurring Radioactive Material (TENORM) can be a potential health risk. It is now well known that the underlying geology in many parts of Texas has given rise to levels of (226)Ra and (228)Ra that often exceed the limits set by the US Environmental Protection Agency. A detailed literature search was undertaken to assess the levels of (226)Ra and (228)Ra in all of the Texas counties. Several statistical evaluations of the data were performed. The Hickory aquifer in the Llano Uplift region of Texas has consistently had the highest number of (226)Ra and (228)Ra concentrations above the legal limit. As well many of the affected rural communities may not have the financial resources to rectify the problem.

Determination of ²²⁶Ra, ²²⁸Ra and ²¹⁰Pb in NORM products from oil and gas exploration: problems in activity underestimation due to the presence of metals and self-absorption of photons

Typical calibration of solid environmental samples for the determination of (226)Ra, (228)Ra and (210)Pb entails the use of standard reference materials which have a very similar matrix. However, TENORM samples from the oil and gas exploration contain unusually high amounts of calcium, strontium and barium which can severely attenuate the photons of (210)Pb and (226)Ra with their characteristic 46.1 keV and 186.2 keV gamma-rays, respectively and to some extent (228)Ra with the characteristic gamma-rays of 911.2 keV and 969.0 keV. We used neutron activation analysis to evaluate the content of TENORM for calcium, barium and strontium and then used a software program SELABS to determine the self-absorption. Our results confirm that even in Petrie containers with small dimensions the (210)Pb can be underestimated by almost by a factor of four while (226)Ra can be underestimated by 5%. The (228)Ra activities are virtually unaffected due to the higher energy gamma-rays. However, the implications for TENORM studies that employ large Marinelli containers having sample sizes between 0.25 and 1.0 L may be severely compromised by the presence of high Z elements in elevated concentrations. The usual spectral interferences on (226)Ra, (228)Ra and (210)Pb coming from other radionuclides in the (234)U, (235)U and (238)U decay chains are virtually nonexistent due the very high activity levels of (226)Ra, (228)Ra and (210)Pb in the tens of thousands of Bq/kg.

An evaluation of the effectiveness of the Zambian Health Worker Retention Scheme (ZHWRS) for rural areas

BACKGROUND

Zambian Health Workers Retention Scheme (ZHWRS) commenced in 2003. The schemes' original aim was to retain and recruit Zambian doctors in rural and remote districts. The aim of the ZHWRS subsequently expanded to also include other health workers, in either rural or urban areas. The scheme was formulated to address, in part, the drastic shortage of health workers.

OBJECTIVES

To evaluate the effectiveness of the ZHWRS in achieving its aim.

METHODS

The data on the number of health workers recruited by the ZHWRS and the spatial distribution of them was reviewed. A survey of health workers was undertaken to elicit their views of their working conditions, their job satisfaction and the effectiveness of retention schemes in retaining or increasing the numbers of and overall satisfaction of health workers.

RESULTS

The ZHWRS has not been successful in recruiting sufficient numbers of health workers to reverse the shortage problem or even to meet the modest targets of the scheme itself. However, these improvements do not decrease the likelihood of Department of Health (DoH) workers leaving their rural based positions.

CONCLUSIONS

The ZHWRS has not fully met either its original or revised aims. The drastic shortage of health workers in Zambia continues.

Carcinoma base of tongue: single institution 15 year experiences

AIMS

To report the outcome with radiotherapy and concomitant chemoradiotherapy in patients with locally advanced squamous cell carcinoma base of tongue treated and followed up at single institution over a period of 15 years.

MATERIALS AND METHODS

This study was carried out by auditing the medical records of 103 patients treated at our institution between 1991 and 2006. Mean age with standard deviation of patients in the Radiotherapy only (group I) and chemoradiotherapy (group II) was 55.26 ± 14.16 and 49.81 ± 12.16 years. 46 patients were treated with radiotherapy alone and 57 patients were treated with concurrent chemo radiotherapy using infusion cisplatinum 3 weekly and 5 fluorouracil twice weekly. Mean follow up was 13.35 months. All the patients characteristic and treatment characteristics were recorded.

RESULTS

There were 81 men and 22 women in the study. Group I contains 15 and 31 cases of stage III and IV tumors while group II contains 19 and 38 cases of stage III and IV respectively. Group II has shown improved loco regional control rate for the T3 and T4 tumors as compared to group I. Disease free survival and overall survival in the group II is 25.51 months and 22.53 months while group I has 8.67 months and 6.74 months respectively. Grade III mucosal toxicity incidence was higher in group II as compared to group I.

CONCLUSIONS

In locally advanced squamous cell carcinoma of base of tongue tumors concomitant chemoradiotherapy with infusional cisplatinum and 5 fluorouracil results in higher disease free and overall survival as compared to radiotherapy as single modality. This better tumor response with chemoradiotherapy comes at cost of higher incidence of mucosal toxicity.

Difficult intubation management in a child with I-cell disease

I-cell disease (mucolipidosis II) is a rare metabolic disorder resulting from the deficiency of a specific lysosomal enzyme, N-acetylglucosamine-1-phosphotransferease. Developmental delay and growth failure are common presentations of I-cell disease. Psychomotor deterioration is rapid and progressive. Some physical signs such as hip dislocations, inguinal hernia, hepatomegaly, joint limitation, and skin changes may be present at birth. Coarse facial features and skeletal abnormalities become more conspicuous with time. The life expectancy of children with this condition is poor, with death usually occurring around the fifth year. A case report of the anesthetic management of gingivectomy with multiple dental extractions in a 5-year-old Omani female with I-cell disease is presented. The problems faced and their management during anesthesia are described.

Anesthesia for gingivectomy and dental extractions in a child with I-cell disease--a case report

I-cell disease (mucolipidosis II) is a rare metabolic disorder resulting from the deficiency of a specific lysosomal enzyme, N-acetylglucosamine-1-phosphotransferease. Developmental delay and growth failure are common presentations of I-cell disease. Psychomotor deterioration is rapid and progressive. Some physical signs, such as hip dislocations, inguinal hernia, hepatomegaly, joint limitation, and skin changes may be present at birth. Coarse facial features and skeletal abnormalities become more conspicuous with time. The life expectancy of children with this condition is poor, with death usually occurring around the fifth year. A case report of the anesthetic management of gingivectomy with multiple dental extractions in a 5 years old Omani female, with I-cell disease, is presented. The problems faced and their management during anesthesia are described.

Two novel AIRE mutations in autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) among Indians

Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a rare recessive disorder resulting from mutations in the autoimmune regulator (AIRE) gene. There is no information on AIRE mutations in Indians. In a cross-sectional study, nine patients (eight families), from four referral hospitals in India, were studied for AIRE mutations by direct sequencing. We screened for new mutations in 150 controls by allele-specific PCR. The patients had 1-7 known components of APECED. Three patients had unusual manifestations: presentation with type 1 diabetes; chronic sinusitis and otitis media; and facial dysmorphism. All patients carried homozygous, probably recessive, AIRE mutations. Two unrelated patients from a small in-bred community (Vanika Vaisya) in south India carried an unreported missense mutation, p.V80G, in the N-terminal caspase recruitment domain. Another unique mutation, p.C302X, resulting in a truncated protein with deletion of both zinc-finger domains, was detected in a patient from Gujarat. Neither mutation was detected in controls. Other mutations, previously described in Caucasians, were: 13 base pair deletion (p.C322fsX372) in 4 (38%), and Finn-major (p.R257X) and p.R139X (Sardinian) mutation in one subject each. In conclusion, in this first series of APECED in Indians, we detected AIRE mutations previously reported in Caucasians, as well as unique mutations. Of these, p.V80G is possibly an ancestral mutation in an in-bred community.

Fractures of the atlas: can we rely on the NICE guidelines for imaging the cervical spine after head injury?

We describe a patient who was not thought to fulfil the NICE criteria for imaging the cervical spine after head injury but who had two fractures of the atlas, thus rendering the vertebral ring unstable. The reasons for missing this injury in the emergency department are discussed.

Effect of population ageing on emergency department speed and efficiency: a historical perspective from a district general hospital in the UK

OBJECTIVE

To examine changes in the rate of seeing patients between 1990 and 2004 and to see whether performance might be related to patient age, using data held on the patient administration system.

METHOD

Data collected in 1990 were compared with those collected in 2004. Age related data were examined for the following parameters: the number of patients arriving by ambulance; the time taken to process the attendance; the number of investigations; the number of emergency admissions; and the length of inpatient stay.

RESULTS

Emergency department (ED) performance has fallen markedly since 1990. Between 1990 and 2004, there was a 54% increase in total patients with a disproportionate 198% increase in patients aged more than 70 years, including a 671% increase in those aged more than 90 years. The time taken to manage patients increased with age. In 2004, there was a marked rise in investigation rates, and the probability of having investigations increased with age. In 2004, older patients (aged more than 70 years) were 4.9 times more likely to require admission to hospital than younger patients (aged 30 years or less). Their average length of stay was 6.9 times longer. Younger patients were 3.3 times more numerous than older patients but older patients occupied 9.8 times more emergency bed days.

CONCLUSIONS

Pressure on emergency care is associated with a disproportionate increase in the number of elderly patients and with an increased tendency to investigate them. Population ageing is of central importance in planning health services.

Pitfalls in the clinical diagnosis of vertebral fractures: a case series in which posterior midline tenderness was absent

OBJECTIVE

There is widespread belief among doctors that posterior midline tenderness is virtually a prerequisite for spinal fracture in alert, sober patients without any painful distracting injury or neurological deficit. This paper examines and challenges this belief.

METHODS AND RESULTS

We present three patients in whom significant thoracic and lumbar vertebral fractures were missed, or were thought to be "old", because of lack of posterior midline tenderness. We also present two further patients, one with a lumbar spine fracture and one with a cervical spine fracture, in whom posterior midline tenderness was absent but in whom the correct diagnosis was made. All these patients were sober and fully alert and none had a neurological deficit or a painful distracting injury.

CONCLUSION

The absence of posterior midline tenderness does not exclude significant spinal injury. We suggest that patients should satisfy both the Canadian and British guidelines before it is decided that imaging of the cervical spine is unnecessary.

Perforation of the oesophagus and aorta after eating fish: an unusual cause of chest pain

This report describes perforation of the oesophagus after eating fish complicated by perforation of the aorta six days later. The patient had not knowingly swallowed a fish bone. Aorto-oesophageal fistula is almost universally fatal. In the case described here, the fistula was demonstrated on contrast computed tomography before surgery, thus informing surgical management. The patient is the eighth reported survivor.

Facilities for chemical decontamination in accident and emergency departments in the United Kingdom

OBJECTIVE

To audit the facilities for chemical decontamination, with special reference to cyanide poisoning, in all major accident and emergency departments in the UK.

METHOD

A simple postal questionnaire was used to audit planning, premises, equipment, protection for staff, and stocks of specific antidotes to cyanide poisoning.

RESULTS

227 questionnaires from 261 departments (87%) were returned and used in the survey. Of the 227 departments who responded, 151 (66%) had a written plan; 168 (74%) departments had premises for decontamination; 55 (24%) were judged to have satisfactory premises; 146 (64%) departments had a shower or hose for decontamination; 60 (26%) departments had a decontamination trolley suitable for "stretcher" patients; 203 (89%) had some protective equipment for staff but only 77 (34%) had complete protection--that is, goggles, chemical resistant clothing, and breathing apparatus. In the authors' opinion only seven (3%) departments had satisfactory premises and equipment to treat "stretcher" patients and full protection for staff. A further 11 (5%) departments were equipped to manage ambulant patients at a similar level. Some 205 (90%) departments stocked one or more antidotes to cyanide and 77 (34%) stocked all four antidotes. Thirty four (15%) departments held all four antidotes to cyanide and had full protection for staff. Only five (2%) departments had satisfactory premises and equipment to treat "stretcher" patients, full protection for staff, and at least three of four antidotes.

CONCLUSIONS

Most departments had some equipment for chemical decontamination. However, there were major inconsistencies in the range of equipment held and these limited its usefulness. Only a small minority of departments was satisfactorily equipped to deal with a serious chemical incident.

Kangaroo Mother Care in very low birth weight infants

OBJECTIVE

This study was conducted (i) to study through a randomized control trial the effect of Kangaroo Mother Care (KMC) on breast feeding rates, weight gain and length of hospitalization of very low birth neonates and (ii) to assess the acceptability of Kangaroo Mother Care by nurses and mothers.

METHODS

Babies whose birth weight was less than 1500 Grams were included in the study once they were stable. The effect of Kangaroo Mother Care on breast feeding rates, weight gain and length of hospitalization of very low birth weight neonates was studied through a randomized control trial in 28 neonates. The Kangaroo group (n = 14) was subjected to Kangaroo Mother Care of at least 4 hours per day in not more than 3 sittings. The babies received Kangaroo Care after shifting out from NICU and at home. The control group (n = 14) received only standard care (incubator or open care system). Attitude of mothers and nurses towards KMC was assessed on Day 3 +/- 1 and on day 7 +/- 1 after starting Kangaroo Care in a questionnaire using Likert's scale.

RESULTS

The results of the clinical trial reveal that the neonates in the KMC group demonstrated better weight gain after the first week of life (15.9 +/- 4.5 gm/day vs. 10.6 +/- 4.5 gm/day in the KMC group and control group respectively p < 0.05) and earlier hospital discharge (27.2 +/- 7 vs. 34.6 +/- 7 days in KMC and control group respectively, p < 0.05). The number of mothers exclusively breastfeeding their babies at 6 week follow-up was double in the KMC group than in the control group (12/14 vs. 6/14) (p < 0.05).

CONCLUSION

KMC managed babies had better weight gain, earlier hospital discharge and, more impressively, higher exclusive breast-feeding rates. KMC is an excellent adjunct to the routine preterm care in a nursery.