Impact of universal access to hepatitis C therapy on HIV-infected patients: implementation of the Spanish national hepatitis C strategy

In April 2015, the Spanish National Health System (SNHS) developed a national strategic plan for the diagnosis, treatment, and management of hepatitis C virus (HCV). Our aim was to analyze the impact of this on human immunodeficiency virus (HIV)-infected patients included in the HERACLES cohort during the first 6 months of its implementation. The HERACLES cohort (NCT02511496) was set up in March 2015 to evaluate the status and follow-up of chronic HCV infection in patients co-infected with HIV in the south of Spain. In September 2015, the data were analyzed to identify clinical events (death, liver decompensation, and liver fibrosis progression) and rate of treatment implementation in this population. The study population comprised a total of 3474 HIV/HCV co-infected patients. The distribution according to liver fibrosis stage was: 1152 F0-F1 (33.2 %); 513 F2 (14.4 %); 641 F3 (18.2 %); 761 F4 (21.9 %); and 407 whose liver fibrosis was not measured (12.3 %). During follow-up, 248 patients progressed by at least one fibrosis stage [7.1 %; 95 % confidence interval (CI): 6.3-8 %]. Among cirrhotic patients, 52 (6.8 %; 95 % CI: 5.2-8.9 %) developed hepatic decompensation. In the overall population, 50 patients died (1.4 %; 95 % CI: 1.1-1.9 %). Eight hundred and nineteen patients (23.56 %) initiated interferon (IFN)-free treatment during follow-up, of which 47.8 % were cirrhotic. In our study, during 6 months of follow-up, 23.56 % of HIV/HCV co-infected patients included in our cohort received HCV treatment. However, we observed a high incidence of negative short-term outcomes in our population.

A comparative study of negative pressure wound therapy with and without instillation of saline on wound healing

OBJECTIVE

Negative pressure wound therapy (NPWT) has become an established treatment of traumatic and infected wounds. Negative pressure wound therapy with instillation (NPWTi) is a further development that combines the conventional NPWT with instillation of different fluids which continuously administer therapeutic reagents to the wound. The aim of this study was to compare the impact of additional saline instillation in NPWTi to NPWT alone.

METHOD

Between January and July 2014, consecutive patients with acute wounds of the lower limb were treated with NPWTi with saline instillation. The number of revision surgeries, length of hospital stay, and duration of treatment until final healing were recorded and compared with matched patients undergoing NPWT without instillation.

RESULTS

There were 10 patients recruited with 10 matched controls examined restrospectivley. Patients who received NPWTi were found to have decreased time of hospitalisation (21.5 versus 26.5 days, p=0.43), and accelerated wound healing (9.0 versus 12.5 days, p=0.36) than patients who received NPWT. However, the difference in the outcomes of the patients who received NPWTi and patients who received NPWT was not found to be statisticallly significant.

CONCLUSION

NPWTi with instillation of saline is a promising method and its effectiveness needs to be tested in a randomised controlled trial compared with NPWT alone.

DECLARATION OF INTEREST

This study obtained support by KCI (Wiebsaden, Germany) for the surgical material.

Liver stiffness predicts the response to direct-acting antiviral-based therapy against chronic hepatitis C in cirrhotic patients

The purpose of this investigation was to evaluate the impact of liver stiffness (LS) on the response to direct-acting antiviral (DAA)-based therapy against hepatitis C virus (HCV) infection in cirrhotic patients. Those patients included in two Spanish prospective cohorts of patients receiving therapy based on at least one DAA, who showed a baseline LS ≥ 12.5 kPa and who had reached the scheduled time point for sustained virological response evaluation 12 weeks after completing therapy (SVR12) were analysed. Pegylated interferon/ribavirin-based therapy plus an HCV NS3/4A protease inhibitor (PR-PI group) was administered to 198 subjects, while 146 received interferon-free regimens (IFN-free group). The numbers of patients with SVR12 according to an LS < 21 kPa versus ≥21 kPa were 59/99 (59.6%) versus 46/99 (46.5%) in the PR-PI group (p = 0.064) and 41/43 (95.3%) versus 90/103 (87.4%) in the IFN-free group (p = 0.232). Corresponding figures for the relapse rates in those who presented end-of-treatment response (ETR) were 3/62 (4.8%) versus 10/56 (17.9%, p = 0.024) and 1/42 (2.4%) versus 8/98 (8.2%, p = 0.278), respectively. In a multivariate analysis adjusted for age, sex and use of interferon, a baseline LS ≥ 21 kPa was identified as an independent predictor of relapse [adjusted odds ratio, AOR (95% confidence interval, CI): 4.228 (1.344-13.306); p = 0.014] in those patients with ETR. LS above 21 kPa is associated with higher rates of relapse to DAA-based therapy in HCV-infected patients with cirrhosis in clinical practice. LS could help us to tailor the duration and composition of DAA-based combinations in cirrhotic subjects, in order to minimise the likelihood of relapse.

Arthroscopic Debridement for Irreparable Rotator Cuff Tears

Background:

Arthroscopic debridement represents a salvage procedure for irreparable rotator cuff tears. It is important to accurately diagnose the patient for irreparable rotator cuff tears. The diagnosis and the therapeutic options must be explained to the patient. It is mandatory that the patient understands the primary goal of the arthroscopic debridement being reduction of pain, not improving strength or function.

Methods:

The procedure consists of 7 distinct steps to debride the soft tissues and alleviate pain.

Results:

Even though there is a lack of evidence that this procedure is superior to other therapeutic options, it has shown good results in patients with the main complaint of pain.

Conclusion:

The results reported in some studies should, however, be interpreted with caution, taking into consideration the substantial structural damage in irreparable defects.

Efficacy and safety of liraglutide compared to sulphonylurea during Ramadan in patients with type 2 diabetes (LIRA-Ramadan): a randomized trial

AIMS

Compare effects of liraglutide 1.8 mg and sulphonylurea, both combined with metformin, on glycaemic control in patients with type 2 diabetes (T2D) fasting during Ramadan.

MATERIALS AND METHODS

In this up to 33-week, open-label, active-controlled, parallel-group trial, adults [glycated haemoglobin (HbA1c) 7%-10% (53-86 mmol/mol); body mass index ≥20 kg/m(2) ; intent to fast] were randomized (1:1) ≥10 weeks before Ramadan to either switch to once-daily liraglutide (final dose 1.8 mg) or continue pre-trial sulphonylurea at maximum tolerated dose, both with metformin.

PRIMARY ENDPOINT

change in fructosamine, a validated marker of short-term glycaemic control, during Ramadan.

RESULTS

Similar reductions in fructosamine levels were observed for both groups during Ramadan [liraglutide (-12.8 µmol/L); sulphonylurea (-16.4 µmol/L); estimated treatment difference (ETD) 3.51 µmol/L (95% CI: -5.26; 12.28); p = 0.43], despite lower fructosamine levels in the liraglutide group at start of Ramadan. Fewer documented symptomatic hypoglycaemic episodes were reported in liraglutide-treated (2%, three subjects) versus sulphonylurea-treated patients (11%, 18 subjects). No severe hypoglycaemic episodes were reported by either group. Body weight decreased more during Ramadan with liraglutide (ETD: -0.54 kg; 95% CI: -0.94;-0.14; p = 0.0091). The proportion of patients reporting adverse events was similar between groups. Liraglutide led to greater HbA1c reduction [ETD: -0.59% (-6.40 mmol/mol), 95% CI: -0.79; -0.38%; -8.63; -4.17 mmol/mol; p < 0.0001].

CONCLUSIONS

Despite lower fructosamine levels and body weight at the beginning of Ramadan, use of liraglutide showed similar glycaemic improvements, fewer hypoglycaemic episodes and greater body weight reduction compared with sulphonylurea. LIRA-Ramadan provides evidence for liraglutide being safe and efficacious for management of T2D during Ramadan fasting.

Non-Operative Management of Rotator Cuff Tears

Background:

The role of nonoperative management for rotator cuff tears remains a matter of debate. Clinical results reported in the literature mainly consist of level IV studies, oftentimes combining a mixed bag of tear sizes and configurations, and are contradictory to some extent.

Methods:

A selective literature search was performed and personal surgical experiences are reported.

Results:

Most studies show an overall success rate of around 75% for nonoperative treatment. However, the majority of studies also present a progression of tear size and fatty muscle infiltration over time, with however debatable clinical relevance for the patient. Suggested factors associated with progression of a rotator cuff tear are an age of 60 years or older, full-thickness tears, and fatty infiltration of the rotator cuff muscles at the time of initial diagnosis.

Conclusion:

Non-operative management is indicated for patients with lower functional demands and moderate symptoms, and/or of course for those refusing to have surgery. Close routinely monitoring regarding development of tear size should be performed, especially in patients that remain symptomatic during nonoperative treatment. To ensure judicious patient counseling, it has to be taken into account that 1) tears that are initially graded as reparable may become irreparable over time, and 2) results after secondary surgical therapy after failed nonoperative treatment are usually reported to be inferior to those who underwent primary tendon repair.

Efficacy and safety of switching to abacavir/lamivudine (ABC/3TC) plus rilpivirine (RPV) in virologically suppressed HIV-infected patients on HAART

We analysed the efficacy and safety of switching from a regimen based on nonnucleoside reverse transcriptase inhibitors (NNRTI) or integrase inhibitors (INI) to ABC/3TC + RPV in virologically suppressed HIV-infected patients. This multicentre, retrospective study comprised asymptomatic HIV-infected patients who switched from 2 NRTI + NNRTI or 2 NRTI + INI to ABC/3TC + RPV between February 2013 and December 2013; all had undetectable HIV viral load prior to switching. Efficacy and safety, and changes in lipids and cardiovascular risk (CVR) were analysed at 48 weeks. Of 85 patients (74.1 % men, mean age 49.5 years), 83 (97.6 %) switched from a regimen based on NNRTI (EFV 74, RPV 5, ETV 2, NVP 2), and 45 (53 %) switched from TDF/FTC to ABC/3TC. The main reasons for switching were toxicity (58.8 %) and convenience (29.4 %). At 48 weeks, 78 (91.8 %) patients continued taking the same regimen; efficacy was 88 % by intention to treat, and 96 % by per protocol. Two patients were lost to follow-up and five ceased the new regimen (4 due to adverse effects and 1 virologic failure). Mean CD4 cell counts increased (744 vs. 885 cells/μL; p = 0.0001), and there were mean decreases in fasting total cholesterol (-15.9 mg/dL; p < 0.0001) and LDL-cholesterol (-11.0 mg/dL; p < 0.004), with no changes in HDL-cholesterol, triglycerides, total cholesterol:HDL-cholesterol ratio, and CVR. ABC/3TC + RPV is effective and safe in virologically-suppressed patients on antiretroviral therapy (ART). Forty-eight weeks after switching the lipid profile improved with decreases in total and LDL cholesterol.

[Negative Pressure Wound Therapy with Instillation in the Treatment of Critical Wounds]

BACKGROUND

In recent decades, negative pressure wound therapy (NPWT) has become the gold standard in the treatment of infected wounds. Negative pressure wound therapy with instillation (NPWTi) is a new development, that combines conventional NPWT with instillation of fluids.

OBJECTIVES

The purpose of this study was to review the results of current literature on the clinical use of NPWTi in acute and chronic wounds.

MATERIAL AND METHODS

A literature search was performed using Pubmed and the Cochrane Library, including articles in English and German.

RESULTS

The data suggest that NPWTi is a promising therapeutic option in the treatment of wounds, and applicable in various fields.

CONCLUSIONS

NPWTi appears to be a useful adjunct in the treatment of critical wounds. However, data from prospective randomised trials to support the validity of the results are sparse.

[Sagittal Balance of the Spine--Clinical Importance and Radiographic Assessment]

Sagittal deformities of the spine frequently result in back pain, as patients have to expend much energy in compensation. The sagittal alignment of the spine is defined by its curvatures (lordosis and kyphosis) relative to the position of the pelvis. Diagnostic assessment is based on full spine a. p. and lateral X-rays. The sagittal balance is primarily described by different angles that can be measured, e.g. lumbar lordosis, pelvic incidence, pelvic tilt and thoracic kyphosis. The quality of life can best be estimated by subtracting lumbar lordosis from the pelvic incidence. However, initial evaluation of the sagittal balance can also be based on the sagittal vertical axis. The severity of imbalance can be described by the sagittal vertical axis and the pelvic tilt, but surgical therapy necessitates a more profound analysis, which can be based on the SRS-Schwab classification.

Management of anterior caliceal stones >15 mm

Anterior caliceal stones represent a challenge to endourologist to select the best modality of management with the least morbidity. To study different treatment modalities of management of anterior caliceal stones >15 mm. It is an observational prospective study of patients with anterior caliceal stones more than 15 mm. Inclusion criteria were patients with isolated anterior caliceal stones, or branched anterior caliceal stones with posterior caliceal extension. Patients were evaluated using non-contrast CT preoperatively. They were divided into three groups: group 1 underwent PCNL through posterior caliceal puncture in cases with wide anterior calyx infundibulum or obtuse infundibulopelvic pelvic, group 2 underwent PCNL through anterior caliceal access in cases with narrow infundibulum or acute infundibulopelvic angel and group 3 underwent flexible ureteroscopy and laser lithotripsy. Intraoperative and postoperative findings were recorded and compared. Eighty eight patients were included in this study, Group 1 (44 patients) group 2 (28 patients), and group 3 (16 patients). Operative time was not significantly different across the three groups (68 ± 11.5, 72 ± 9 and 74 ± 11 min in group 1, 2 and 3, respectively, P = 0.053). Fluoroscopy time was significantly shorter for group 3 (2 ± 0.5 m, P = 0.0001) compared to group 1 and 2 (5.6 ± 4.6 and 4.5 ± 1.4 min), respectively. There were no significant differences in stone-free rates after initial treatment between the three groups; 84, 82, and 69 %, in groups 1, 2 and 3, respectively (P = 0.4). Postoperative hemoglobin drop was noted to be highest for group 2 and lowest for group 3 which was significantly different (1.7 ± 0.8, 2.2 ± 1.1, and 0.3 ± 0.3 g/dl, for patients in groups 1, 2 and 3 respectively, P = 0.0001). Group 2 showed the highest post-operative complication rate (21 %) in comparison to group 1 (11 %) and group 3 (6 %), however, differences were not statistically significant (P = 0.3). PCNL through posterior or anterior caliceal puncture is an excellent modality to treat anterior caliceal stones with high stone clearance rate. Despite the higher chance of bleeding with anterior caliceal puncture, it is still inevitably needed in difficult anterior caliceal stones with unfavorable anatomy. RIRS is a good alternative to PCNL with the advantage of less radiation exposure and less bleeding.

Ionoacoustic characterization of the proton Bragg peak with submillimeter accuracy

PURPOSE

Range verification in ion beam therapy relies to date on nuclear imaging techniques which require complex and costly detector systems. A different approach is the detection of thermoacoustic signals that are generated due to localized energy loss of ion beams in tissue (ionoacoustics). Aim of this work was to study experimentally the achievable position resolution of ionoacoustics under idealized conditions using high frequency ultrasonic transducers and a specifically selected probing beam.

METHODS

A water phantom was irradiated by a pulsed 20 MeV proton beam with varying pulse intensity and length. The acoustic signal of single proton pulses was measured by different PZT-based ultrasound detectors (3.5 and 10 MHz central frequencies). The proton dose distribution in water was calculated by Geant4 and used as input for simulation of the generated acoustic wave by the matlab toolbox k-WAVE.

RESULTS

In measurements from this study, a clear signal of the Bragg peak was observed for an energy deposition as low as 10(12) eV. The signal amplitude showed a linear increase with particle number per pulse and thus, dose. Bragg peak position measurements were reproducible within ±30 μm and agreed with Geant4 simulations to better than 100 μm. The ionoacoustic signal pattern allowed for a detailed analysis of the Bragg peak and could be well reproduced by k-WAVE simulations.

CONCLUSIONS

The authors have studied the ionoacoustic signal of the Bragg peak in experiments using a 20 MeV proton beam with its correspondingly localized energy deposition, demonstrating submillimeter position resolution and providing a deep insight in the correlation between the acoustic signal and Bragg peak shape. These results, together with earlier experiments and new simulations (including the results in this study) at higher energies, suggest ionoacoustics as a technique for range verification in particle therapy at locations, where the tumor can be localized by ultrasound imaging. This acoustic range verification approach could offer the possibility of combining anatomical ultrasound and Bragg peak imaging, but further studies are required for translation of these findings to clinical application.

[New therapy approaches for giant cell tumors]

BACKGROUND

Giant cell bone tumors (GCT) are benign but partially locally aggressive osteolytic tumors which typically occur around the knee joint in the epiphysis and metaphysis of long bones after maturation of the skeleton is completed. Due to the locally aggressive growth behavior with destruction of the bone structure, the rare possibility of pulmonary metastases in recurrent cases and a very rare possibility of malignancy, GCTs were previously also described as semimalignant bone tumors.

THERAPY

The established therapy of these tumors at the typical locations consists of intralesional curettage, extension of resection margins using a high speed trephine and defect reconstruction with bone cement. The local recurrence rate is high (10-40 %) and lowest after using thermal extension of resection margins with a high speed trephine and defect reconstruction with bone cement. For uncommon localizations, such as the spinal column and the sacrum as well as in cases of recurrence, surgical treatment is more complicated.

HISTOLOGY

Histologically, GCTs consist of osteoclastic giant and oval-shaped stromal cells which show a high expression of receptor activator of nuclear factor-κB ligand (RANKL) and decisively contribute to the osteolytic activity of the tumor. Novel pharmaceutical therapy approaches with human monoclonal RANKL antibodies interfere in this osteodestructive process in an inhibitory manner and can represent alternative treatment options just as the osteosupportive therapy with bisphosphonates.

CONCLUSION

After unsatisfactory attempts at surgical treatment of GCT patients, the new treatment option with denosumab is a promising alternative due to its effect as a monoclonal RANKL inhibitor.

Synovial C-reactive protein as a marker for chronic periprosthetic infection in total hip arthroplasty

The aim of this study was to assess the role of synovial C-reactive protein (CRP) in the diagnosis of chronic periprosthetic hip infection. We prospectively collected synovial fluid from 89 patients undergoing revision hip arthroplasty and measured synovial CRP, serum CRP, erythrocyte sedimentation rate (ESR), synovial white blood cell (WBC) count and synovial percentages of polymorphonuclear neutrophils (PMN). Patients were classified as septic or aseptic by means of clinical, microbiological, serum and synovial fluid findings. The high viscosity of the synovial fluid precluded the analyses in nine patients permitting the results in 80 patients to be studied. There was a significant difference in synovial CRP levels between the septic (n = 21) and the aseptic (n = 59) cohort. According to the receiver operating characteristic curve, a synovial CRP threshold of 2.5 mg/l had a sensitivity of 95.5% and specificity of 93.3%. The area under the curve was 0.96. Compared with serum CRP and ESR, synovial CRP showed a high diagnostic value. According to these preliminary results, synovial CRP may be a useful parameter in diagnosing chronic periprosthetic hip infection.

Cite this article: Bone Joint J 2015; 97-B:173–6.

COMPARATIVE STUDY ON THE LEVEL OF BACTERIOLOGICAL CONTAMINATION OF AUTOMATIC TELLER MACHINES, PUBLIC TOILETS AND PUBLIC TRANSPORT COMMERCIAL MOTORCYCLE CRASH HELMETS IN KIGALI CITY, RWANDA

BACKGROUND

The environments can be contaminated by infectious agents that constitute a major health hazards as sources of community and hospital-acquired infections due to various activities.

OBJECTIVE

A comparative study on the level of bacteriological contamination of automatic teller machines (ATMs), public toilets and commercial motorcycle crash helmets were conducted in Kigali city during the period of January to March, 2013.

DESIGN

Samples were collected from selected ATMs, public toilets and commercial motorcycle crash helmets surfaces. Micro-organisms identified from these samples were associated to infecting organisms recovered from unwashed hands surfaces and recorded results in the nearby hospital.

SETTING

Samples from each device and subject were transported to the laboratory where they were analysed for the presence of coliforms and other airborne, human skin and intestinal disease causing microorganisms. Microbiological methods including spread plate techniques and some biochemical tests were used to partially identify the microorganisms.

SUBJECTS

Subjects involved in this study were consented students from University of Rwanda and Kigali motorcyclists for collections of samples from hands and crash helmets respectively.

RESULTS

The following pathogenic bacteria have been found on the devices, Staphylococcus aureus, Staphylococcus epidermis, Streptococcus species, Escherichia coli, Salmonella, Klebsiella, Enterobacter aerogenes, Pseudomonas. The commercial motorcycle crash helmets had the highest level of bacteriological contamination compared to ATMs and public toilets. There was no growth observed on samples collected after treatment from ATMs, public toilets, and commercial motorcycle crash helmets. Attempt to correlate this finding with infecting organisms recovered from unwashed hands surfaces and recorded results in the nearby hospital show that the presences of some of these infectious pathogens.

CONCLUSION

This study has revealed the ability of these public devices to serve as vehicle of transmission of microorganisms with serious health implications. To improve and ensure the safety of these public devices the use of disinfectants is of high importance on reducing bacteriological load on those public devices. Proper cleaning regimen to sanitise these facilities regularly and public education on their hygienic usage are recommended to reduce the associated risks.

Assessment of natural radioactivity levels in rocks and their relationships with the geological structure of Johor state, Malaysia

The distribution of natural radionuclides ((238)U, (232)Th and (40)K) and their radiological hazard effect in rocks collected from the state of Johor, Malaysia were determined by gamma spectroscopy using a high-purity germanium detector. The highest values of (238)U, (232)Th and (40)K activity concentrations (67±6, 85±7 and 722±18 Bg kg(-1), respectively) were observed in the granite rock. The lowest concentrations of (238)U and (232)Th (2±0.1 Bq kg(-1) for (238)U and 2±0.1 Bq kg(-1) for (232)Th) were observed in gabbro rock. The lowest concentration of (40)K (45±2 Bq kg(-1)) was detected in sandstone. The radium equivalent activity concentrations for all rock samples investigated were lower than the internationally accepted value of 370 Bq kg(-1). The highest value of radium equivalent in the present study (239±17 Bq kg(-1)) was recorded in the area of granite belonging to an acid intrusive rock geological structure. The absorbed dose rate was found to range from 4 to 112 nGy h(-1). The effective dose ranged from 5 to 138 μSv h(-1). The internal and external hazard index values were given in results lower than unity. The purpose of this study is to provide information related to radioactivity background levels and the effects of radiation on residents in the study area under investigation. Moreover, the relationships between the radioactivity levels in the rocks within the geological structure of the studied area are discussed.

A preliminary study of job satisfaction and motivation among the Malaysian primary healthcare professionals

AIM

This study aimed to examine the relationship between personal or work-based characteristics and job satisfaction and motivation in Malaysian primary healthcare professionals.

METHODS

This was a cross-sectional survey conducted during the 15th Family Medicine Scientific Conference in June 2011 using the Warr-Cook-Wall scales. The questionnaires included demography and work-related items and were self-distributed and returned at the end of the conference. Independent risk factors were identified using multiple linear regressions.

RESULTS

A total of 149 conference participants completed the survey, with a response rate of 33.1%. They were mainly females (85.2%), Malay (83.2%), and married (83.9%) in almost equal proportions of practice location (urban 57.8% and rural 42.2%). Majority of them were working at community-based health clinics (74.0%) and in public sectors (94.4%). The respondents were mainly doctors (91.4%). The mean age of the participants was 39.1 years (SD 8.0), with a mean duration of service of 9 years (SD 6.9). Family medicine specialty (FMSt) residents had lower job satisfaction (B = -8.0, 95% CI -14.61 to -1.40, p = 0.02). Family medicine specialists (FMSs) had higher satisfaction with working conditions (B = 1.95, 95% CI 0.50 to 3.41, p = 0.01). A male worker had on average 2.8 (95% CI -4.7 to -0.9, p = 0.005) lower points in the total intrinsic job motivation scale. There was a positive relationship between the duration of working and job motivation (B = 0.10, 95% CI 0.004 to 0.2, p = 0.04).

CONCLUSION

FMSt residents might have the least job satisfaction, but FMSs were generally satisfied with their working conditions regardless of the location of their clinics. Men and those who were novice in primary healthcare may need more support for motivation.

Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) guideline

BACKGROUND AND AIM

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the choice amongst regimens available for cleansing the colon in preparation for colonoscopy.

METHODS

This Guideline is based on a targeted literature search to evaluate the evidence supporting the use of bowel preparation for colonoscopy. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adopted to define the strength of recommendation and the quality of evidence.

RESULTS

The main recommendations are as follows. (1) The ESGE recommends a low-fiber diet on the day preceding colonoscopy (weak recommendation, moderate quality evidence). (2) The ESGE recommends a split regimen of 4 L of polyethylene glycol (PEG) solution (or a same-day regimen in the case of afternoon colonoscopy) for routine bowel preparation. A split regimen (or same-day regimen in the case of afternoon colonoscopy) of 2 L PEG plus ascorbate or of sodium picosulphate plus magnesium citrate may be valid alternatives, in particular for elective outpatient colonoscopy (strong recommendation, high quality evidence). In patients with renal failure, PEG is the only recommended bowel preparation. The delay between the last dose of bowel preparation and colonoscopy should be minimized and no longer than 4 hours (strong recommendation, moderate quality evidence). (3) The ESGE advises against the routine use of sodium phosphate for bowel preparation because of safety concerns (strong recommendation, low quality evidence).

Eighteen-year follow-up after rotationplasty for a grade IIIC open fracture of the distal femur

We report the 18-year follow-up of a patient who underwent rotationplasty for severe bone loss and infection after an grade IIIC open fracture of the distal femur. The patient is now 49 years old and fully satisfied with his life. During the follow-up period, he has never had significant physical or psychological problems directly concerning the rotationplasty. The analysis of quality of life using the SF36 questionnaire revealed even higher scores than the normal healthy population in seven out of eight sub-categories. Clinical examination revealed bland soft tissues without hyperkeratosis or other signs of maladaptation. Articular and cutaneous proprioception was intact all over the left leg. The active extension/flexion of the prosthetic knee was 0°-0°-100° and 10°-0°-70° of the ankle joint. Manual testing of motor strength revealed grade five of five for dorsiflexion and plantar flexion of the ankle. Gait patterns including climbing slopes and stairs were close to normal. Examination in sports physiology showed lower maximum power of hip and knee muscles compared to the healthy side, but better muscular endurance. These findings emphasize that rotationplasty can be a good alternative to arthrodesis or amputation in trauma patients providing high satisfaction and activity levels in the long-term follow-up.

Field evaluation on the effectiveness of a modified approach of chemical fogging against the conventional fogging in controlling dengue outbreak

A field evaluation on the effectiveness of a modified approach of chemical fogging of insecticides against the conventional method was carried out in the Seremban district within the state of Negeri Sembilan, Malaysia from 7th February 2003 to 7th September 2003. In the 3 months period, November 2002 to January 2003, prior to institution of modified approach of chemical fogging, 27 of 42 (64.3%) dengue outbreaks were successfully controlled within the stipulated time frame of 14 days by the conventional approach of thermal chemical fogging. However, during the period when the modified approach of chemical fogging was instituted, 25 of 27 (92.6%) dengue outbreaks within the same district were successfully controlled within the 14-days time-line. Statistically, the modified approach of chemical fogging significantly improved the success rate of achieving dengue outbreak control within the stipulated time frame (chi2 = 5.65, p = 0.01745). The modified approach of chemical fogging also appeared to reduce the number of dengue cases recorded in the same district. This small pilot study shows that the modified approach of chemical fogging reduced cost in carrying out each fogging activity to control dengue outbreak. It also substantially reduced the required time taken to complete each fogging activity in comparison to the conventional approach. Thus, it enabled similar number of workers to cover more localities simultaneously affected by the outbreaks. In addition, the modified approach reduced the exposure time to hazardous insecticides for each worker doing hand-held thermal fogging.

Malaysian and Thai smokers' beliefs about the harmfulness of 'light' and menthol cigarettes

OBJECTIVE

This study explored the extent to which Malaysian and Thai smokers believe "light" and menthol cigarettes are less harmful than "regular" cigarettes and the correlates of these beliefs.

METHODS

The study used data from wave 1 of the International Tobacco Control Southeast Asia Survey. 2006 adult smokers (95.3% male) from Malaysia and 2000 adult smokers (94.5% male) from Thailand were interviewed face to face in 2005.

RESULTS

29% of Malaysian respondents reported currently smoking light cigarettes and 14% menthols, with 19% agreeing that lights are less harmful and 16% agreeing that menthols are less harmful. 38% of Thai respondents reported currently smoking light cigarettes and 19% menthols, with 46% agreeing that lights are less harmful and 35% agreeing that menthols are less harmful. Malaysian smokers reporting current use of light or menthol cigarettes were more likely to believe that they are less harmful. Reported use of lights did not relate to beliefs for Thai respondents. The belief that light and/or menthol cigarettes are less harmful was strongly related to the belief that they have smoother smoke.

CONCLUSIONS

The experience of smoother smoke is likely to produce some level of belief in reduced harm, regardless of how brands are labelled and whether or not Federal Trade Commission FTC/International Organisation for Standardisation tar, nicotine and carbon monoxide yield figures are used.

Association of low heart rate variability with atherosclerotic cardiovascular disease in hemodialysis patients

OBJECTIVE

The aim of this study was to investigate the left-ventricular (LV) mass-adjusted association between low heart rate variability (HRV) and atherosclerotic cardiovascular disease (ASCVD) among hemodialysis patients in Kuwait.

SUBJECTS AND METHODS

One hundred and eight patients were enrolled in the study. HRV time domain measures were obtained by 48-hour Holter monitoring, including the standard deviation of all R-wave-to-R-wave (RR) intervals (SDNN), standard deviation of all 5-min averaged intervals (SDANN), HRV triangular index (HRV-TI), percent of adjacent RR intervals differing by >50 ms (pNN50), and root mean square of sums of squares of all differences (rMSSD). Left ventricular ejection fraction (LVEF) and LV mass index (LVMI) were measured by M-mode echocardiography. Comorbidity was assessed using medical record review. Prevalent ASCVD was defined as coronary artery, cerebrovascular, or peripheral vascular disease.

RESULTS

Prevalence of ASCVD, LV hypertrophy, and LVEF <40% were 56, 59, and 10%, respectively. The SDANN was negatively associated with ASCVD (-20 ms; p = 0.003), LV systolic dysfunction (-20 ms; p = 0.001), elevated LVMI (-20 ms; p = 0.002), hypertension (-34 ms; p = 0.01), and diabetes (-20 ms; p = 0.001). After adjustment for hypertension and LVMI using logistic regression, ASCVD was associated with the lowest quartile of SDANN (OR = 4.3, p = 0.009), HRV-TI (OR = 3.3, p = 0.03), and SDNN (OR = 2.3, p = 0.10). These associations persisted after adjusting for LVEF.

CONCLUSION

In dialysis patients, low HRV indices were strongly associated with prevalent ASCVD, independent of LVMI and LVEF. The interrelationships among HRV, diabetes, hypertension, and LVMI should be addressed in studies of HRV and ASCVD.

New steroidal anti-inflammatory antedrugs: 21-thioalkylether derivatives of methyl 16-prednisolone carboxylates

Antedrug approach of the corticosteroids has been described as a fundamentally sound approach for the development of safer anti-inflammatory steroids devoid of systemic side effects. In our continued efforts under the antedrug paradigm, we have recently extended this effort to synthesize the 21-thioalkylether derivatives of methyl 16-prednisolonecarboxylates. The 21-mesylate of the methyl-16-perdnisolonecarboxylates and 9-fluoro-17-dehydro methyl 16-prednisolonecarboxylate were reacted with Na-thioalkoxides to furnish the desired thioalkylethers in 60-75% yields. These newly synthesized thioalkylether steroid series were tested for their in vitro metabolism and corticosteroid receptor binding affinity. They were metabolized in predictable manner to inactive 16-carboxylic acids. All the newly synthesized antedrugs showed lowered glucocorticoid receptor binding affinity than prednisolone indicating that the replacement of the 21-OH function with thioalkylether of the 16-prednisolone carboxylate esters decreases their receptor binding affinity.

Radiation dose assessment at amang processing plants in Malaysia

Measurements of external radiation level, radon/thoron daughters concentrations in air and uranium/thorium concentrations in airborne mineral dust at 16 amang plants in Malaysia were carried out for three consecutive months to assess radiation dose to workers. Estimated occupational dose was within the range of 1.7-10.9 mSv y(-1). The mean total dose at the amang plants was 4.1 mSv y(-1). Overall, it was found that the major dose contribution of 80% came from external radiation. Radon/thoron daughters and airborne mineral dust contributed to only 11 and 9% of the total dose, respectively.

Radiation exposure during travelling in Malaysia

Absorbed dose rates in vehicles during travelling by different modes of transport in Malaysia were measured. Radiation levels measured on roads in Peninsular Malaysia were within a broad range, i.e. between 36 and 1560 nGy h(-1). The highest reading, recorded while travelling near monazite and zircon mineral dumps, was 13 times the mean environmental radiation level of Malaysia. It is evident that radioactive material dumps on the roadsides can influence the radiation level on the road. The absorbed dose rates measured while travelling on an ordinary train were between 60 and 350 nGy h(-1). The highest reading was measured when the train passed a tunnel built through a granite rock hill. The measurement during sea travelling by ferries gave the lowest radiation level owing to merely cosmic radiation at the sea level.

Pegylated interferon-alpha 2b-ribavirin combination in Egyptian patients with genotype 4 chronic hepatitis

Egypt has a high prevalence rate of hepatitis C (HCV) infection and as much as 90% is genotype 4. Response to interferon (IFN) varies with viral genotype and degree of fibrosis. Genotype 4 is poorly sensitive to standard IFN and IFN-ribavirin combination. We evaluated pegylated interferon (PEG-IFN)-alpha2b in our patients. Sixty-one patients with compensated chronic HCV genotype 4 were enrolled in two groups: group A (31 patients) received IFN-alpha2b 3 MU three times per week and group B (30 patients) received 1.5 mug/kg PEG-IFN-alpha2b once weekly. Ribavirin was added to each regimen in a dose of 800-1200 mg based on body weight. Patients were followed up for 24 weeks to assess the sustained response (SR). End-of-treatment response (ETR) was achieved in 11 of 31 patients (35.48%) in group A, and 13 of 30 patients (43.33%) in group B (P < 0.05). Only eight patients in group A and 10 in group (B) achieved a sustained virological response (25.8 and 33.3%, respectively) (P < 0.05). By computing ETR, SR or relapse and pretreatment baseline data (pretreatment, viral load, alanine transaminases, necroinflammatory and hepatic fibrosis), both inter- and intragroup, no significant correlations could be detected. In terms of safety and tolerability, PEG-IFN-alpha2b and IFN-alpha2b were comparable. In spite of mild insignificant increase in ETR and SR with the pegylated form, the poor response of genotype 4 in Egypt (genotype 4a) to different forms of IFNs may be related to an intrinsic resistance to the direct antiviral effect of IFN.

Distribution of radium in oil and gas industry wastes from Malaysia

Radium concentrations in 470 samples of the various types of waste from oil and gas industries were analysed using gamma spectrometers. The results showed that the radium concentration varied within a wide range. The highest mean 226Ra and 228Ra concentrations of 114,300 and 130,120 Bq/kg, respectively, were measured in scales. Overall, 75% of the waste, mostly sludge and extraction residue lies within the normal range of radium concentration in soils of Malaysia. However, some platform sludge can have radium concentration up to 560 Bq/kg.

The adequacy of diabetic care for children in a developing country

A cross-sectional study was conducted over 4 months evaluating the quality of care provided to diabetic children in public children's hospitals in Alexandria, Egypt.

RESULTS

Adult diabetologists were the main healthcare providers (HCP) (60.4%) in the School Health Insurance Hospital followed by paediatric diabetologists in the University Hospital. Insured children had a significantly higher frequency of physical examination, investigations and diabetes education compared to uninsured children. One-quarter of insured and 22% of uninsured children were performing self monitoring of blood glucose, while 45.2% of insured children were checking glucosuria at home compared to 34.0% of uninsured children. Premixed suspensions of biosynthetic human insulin, administered mainly via a syringe, was the most commonly prescribed insulin type with little possibility for personal initiative. Acute diabetic complications were also higher in uninsured compared to insured children. The frequency of these life threatening acute diabetic complications in the school health insurance system is estimated to be approximately 12.7 severe hypoglycaemic and 57.2 hyperglycaemic/ketoacidotic episodes per 1000 diabetic children per year. Recurrence of diabetic emergencies was significantly higher among children of parents with lower educational levels and children living in semiurban and rural residence. Children with recurrent diabetic emergencies had lower educational achievement, and more grade repeating and school absence during the year.

CONCLUSION

The results of this study appear to reflect marked deficiencies in the provision of information to children with diabetes and their parents in a developing country. A need for public-education strategies, consensus about treatment recommendations, use of more flexible insulin regimens, and devices for home monitoring is identified.

Aqueous humor and serum tumor necrosis factor-alpha in clinical uveitis

OBJECTIVE

To study the local and systemic behavior of the tumor necrosis factor-alpha (TNF-alpha) in patients with active uveitis.

METHODS

TNF-alpha levels were measured in aqueous humor and peripheral blood samples using an enzyme-linked immunosorbent assay from 23 patients with uveitis and 16 control patients who had been operated on for uncomplicated cataracts.

RESULTS

Aqueous humor and sera of patients with uveitis showed higher levels of TNF-alpha than those of controls (p < 0.001). A comparison of cytokine levels between aqueous humor and sera showed significantly higher levels of TNF-alpha in serum than aqueous humor (p < 0.001). Correlation studies using the regression test for successive steps showed that serum TNF-alpha levels correlated with recurrent uveitis (r = 0.4150; p = 0.0489).

CONCLUSIONS

TNF-alpha is a cytokine that participates actively in the pathogenesis of clinical uveitis. Our data emphasize the greater systemic than local participation of TNF-alpha. Finally, an elevated serum TNF-alpha seems to be associated with a recurrent pattern of uveitis.

Teeth and blood lead levels in Egyptian schoolchildren: relationship to health effects

The objective of this work was to study teeth and blood lead levels in Egyptian schoolchildren and to relate lead levels to sociodemographic and environmental factors, the degree of urbanization and suspected manifestations of possible lead exposure. The study was conducted on 60 children aged 6-12 years: 30 children living in an urban area at Alexandria City and 30 children living in a rural area at Kafr El-Sheikh Province. Both groups are matched for age and gender. Every child was subjected to history taking, clinical examination and IQ measurements. Laboratory investigations included measuring teeth and blood lead levels, haemoglobin, serum iron and total iron binding capacity. The results showed that the mean blood lead level of children in Alexandria was significantly higher than that of the children in Kafr El-Sheikh; also 56.7% and 6.7% of children from Alexandria and Kafr El-Sheikh had a blood lead level of >20 microg dl(-1), with the most frequent symptoms of headache, arthralgia and lack of school interest. The children in Alexandria had significantly lower mean teeth lead and haemoglobin levels than those of the Kafr El-Sheikh group. A history of wrapping sandwiches in newspapers, age and distance between the home and school were significant predictors of lead exposure. These findings support the concept that teeth lead concentration may be a valid addition to the indicators used for assessment of the body burden of environmental lead. In addition, children living in urban areas such as Alexandria need special consideration regarding protection from lead exposure, as well as teeth and blood lead evaluation.

[Aqueous humor and serum interleukin-6 in patients with uveitis]

PURPOSE

A study on local and systemic behavior of interleukin-6 in patients with active uveitis.

METHODS

IL-6 levels were measured in aqueous humor and peripheral blood samples using an enzyme-linked immunosorbent assay (ELISA) from 23 patients with uveitis and 16 control patients who had been operated for uncomplicated cataracts.

RESULTS

Aqueous humor of patients with uveitis showed higher levels of interleukin-6 than those of controls (p<0.001). A comparison of cytokine levels between aqueous humor and serum from patients with uveitis showed significantly higher levels of interleukin-6 in aqueous than serum (p<0.001). Correlation studies using regression test for successive steps failed to demonstrate any association between interleukin-6 levels and the different clinical characteristics of uveitis patients (laterality, onset, patterns, visual damage, localization, inflammatory activity, etiology, and association with the B27 + histocompatibility antigen).

CONCLUSIONS

IL-6 is a cytokine that actively participates in the pathogenesis of clinical uveitis. Our data emphasize the greater local than systemic participation of this cytokine.