Community-centred eco-bio-social approach to control dengue vectors: an intervention study from Myanmar

Objectives

To build up and analyse the feasibility, process, and effectiveness of a partnership-driven ecosystem management intervention in reducing dengue vector breeding and constructing sustainable partnerships among multiple stakeholders.

Methods

A community-based intervention study was conducted from May 2009 to January 2010 in Yangon city. Six high-risk and six low-risk clusters were randomized and allocated as intervention and routine service areas, respectively. For each cluster, 100 households were covered. Bi-monthly entomological evaluations (i.e. larval and pupal surveys) and household acceptability surveys at the end of 6-month intervention period were conducted, supplemented by qualitative evaluations.

Intervention description

The strategies included eco-friendly multi-stakeholder partner groups (Thingaha) and ward-based volunteers, informed decision-making of householders, followed by integrated vector management approach.

Findings

Pupae per person index (PPI) decreased at the last evaluation by 5.7% (0.35–0.33) in high-risk clusters. But in low-risk clusters, PPI remarkably decreased by 63.6% (0.33–0.12). In routine service area, PPI also decreased due to availability of Temephos after Cyclone Nargis. As for total number of pupae in all containers, when compared to evaluation 1, there was a reduction of 18.6% in evaluation 2 and 44.1% in evaluation 3 in intervention area. However, in routine service area, more reduction was observed. All intervention tools were found as acceptable, being feasible to implement by multi-stakeholder partner groups.

Conclusions

The efficacy of community-controlled partnership-driven interventions was found to be superior to the vertical approach in terms of sustainability and community empowerment.

Location of urethral arteries by colour Doppler ultrasound

STUDY DESIGN

A case report.

SETTING

Regional Spinal Injuries Centre, Southport, UK.

CASE REPORT

A 56-year-old male with complete paraplegia at T-4 underwent visual internal urethrotomy of bulbous urethral stricture with a cold knife at 12 o'clock position. There was brisk arterial bleeding. Despite receiving antibiotics, this patient developed hypotension, tachycardia and tachypnoea. He was resuscitated and mechanical ventilation was instituted. After he recovered from this life-threatening episode of urinary tract-related sepsis, colour Doppler ultrasound imaging of bulbous urethra was performed to locate urethral arteries. In the bulbous urethra, single urethral artery was seen at 12 o'clock position.

CONCLUSION

Since the sites of urethral arteries vary among patients, it is advisable to assess individually the location of urethral arteries preoperatively and plan the site of incision accordingly. Persons with injury to cervical or upper dorsal spinal cord have decreased cardiac and respiratory reserve as well as alteration in immune function. Therefore, all possible measures should be taken to prevent acute blood loss and bacteraemia in this group of patients.

Do spinal cord injury patients always get the best treatment for neuropathic bladder after discharge from regional spinal injuries centre?

OBJECTIVE

To draw attention to inadequate care received by some spinal cord injury patients after discharge from the regional spinal injury center.

SETTING

Regional Spinal Injuries Centre, Southport, UK.

METHODS

Presence of the urethral stricture was not recognised in a 69-year-old male with T-3 paraplegia, who attended a health-care facility with a urinary infection. A Foley catheter was inserted into the urethra only half-way and the catheter balloon was then inflated in the urethra distal to the stricture. In a 68-year-old male with T-8 paraplegia, a long-term indwelling catheter was eroding the urethra and he developed a severe degree of hypospadias while being managed in the community. A 49-year-old male with C-4 tetraplegia developed recurrent urine infections. He received several courses of antibiotics, which were prescribed by community health professionals. But he continued to be unwell. Subsequently, the patient was admitted to a district general hospital, where he was diagnosed to have mild chest infection and was about to be sent home. However, his wife was not happy, and then ultrasound of abdomen was taken, which revealed pyonephrosis. He was then transferred to a spinal unit.

RESULTS

: These patients were not seen promptly in a regional spinal injury centre when they developed medical problems. The complications, which ensued, might have been prevented if expert medical treatment had been provided without delay.

CONCLUSION

In order to meet the needs of a growing population of persons living in the community with spinal cord injury, more beds are required in spinal units. Provision of day surgery wards within spinal units, out-reach clinics and home visits by spinal cord clinicians may reduce the demand for admission in a spinal unit. Education of community health professionals on delayed complications of spinal cord injury, and good communication between spinal cord clinicians, patients, carers, and community health professionals by telephone, e-mail or conventional postal system are likely to improve the care of spinal cord injury patients after discharge from spinal injury centres. Spinal cord clinicians should adopt a patient-centred care instead of the traditional, paternalistic, doctor-centred care.

Delayed complications of discontinuation of intrathecal baclofen therapy: resurgence of dyssynergic voiding, which triggered off autonomic dysreflexia and hydronephrosis

STUDY DESIGN

Case report.

OBJECTIVES

To report insidious development of autonomic dysreflexia and hydronephrosis due to dyssynergic voiding following discontinuation of intrathecal baclofen therapy.

SETTING

Regional Spinal Injuries Centre, Southport, UK.

METHODS

A male patient with paraplegia at T-5 (ASIA-A) had implantation of Medtronic Synchromed 8615 s programmable pump to control intractable spasms. After 4 years, the baclofen pump needed replacement because of battery exhaustion. At this time, he was taking oxybutynin 2.5 mg twice a day. He wore a penile sheath and performed intermittent catheterisation three times a day. Intravenous urography showed no dilatation of pelvicalyceal systems or ureters. During the course of the next 4 months, the dose of baclofen had to be increased gradually to 820 microg/day in order to control the spasms. Investigations revealed disconnection of the tube from the pump. The patient decided to undergo explantation of the pump and discontinue intrathecal baclofen therapy altogether. Following removal of the pump, he was prescribed baclofen 20 mg four times a day and diazepam 5 mg twice a day. He continued penile sheath drainage with oxybutynin 2.5 mg twice a day. Although spasms were controlled with oral baclofen and diazepam, he started getting transient, mild headache during reflex voiding. After nearly 2 years, he developed unbearable and pounding headache while passing urine.

RESULTS

The dose of oxybutynin was increased to modified release formulation, 20 mg, once daily. He was prescribed modified release alfuzosin 10 mg once a day. Indwelling urethral catheter drainage was instituted. Intravenous urography showed dilation of left renal pelvis and calyces, and left ureter. After a fortnight, the dose of modified release oxybutynin was increased further to 25 mg once a day. After a month, he started performing self-catheterisation every 3 h and symptoms of autonomic dysreflexia subsided completely. A follow-up intravenous urography performed 6 months later, showed normal appearances of the left kidney.

CONCLUSION

Spinal cord injury patients, in whom intrathecal baclofen therapy is terminated, need close monitoring of their urological status. Medications, which are prescribed for neuropathic bladder, and the method of bladder drainage, may need suitable changes, as discontinuation of intrathecal baclofen therapy can result in reappearance of detrusor-sphincter dyssynergia in previously susceptible patients.

Pseudo-tumours of the urinary tract in patients with spinal cord injury/spina bifida

OBJECTIVE

To raise awareness of pseudo-tumours of urinary tract, as pseudo-tumours represent benign mass lesions simulating malignant neoplasms. Accurate diagnosis helps to avoid unnecessary surgery in spinal cord injury patients.

SETTING

Regional Spinal Injuries Centre, Southport, UK CASE REPORTS: Pseudo-tumour of kidney: A 58-year-old man with tetraplegia developed a right perirenal haematoma while taking warfarin; ultrasound and CT scanning showed no evidence of tumour in the right kidney. The haematoma was drained percutaneously. After 8 months, during investigation of a urine infection, ultrasound and CT scan revealed a space-occupying lesion in the mid-pole of the right kidney. CT-guided biopsy showed features suggestive of an organising haematoma; the lesion decreased in size over the next 13 months, thus supporting the diagnosis. Pseudo-tumour of urinary bladder: A frail, 34-year-old woman, who had spina bifida, marked spinal curvature and pelvic tilt, had been managing her neuropathic bladder with pads. She had recurrent vesical calculi and renal calculi. CT scan was performed, as CT would be the better means of evaluating the urinary tract in this patient with severe spinal deformity. CT scan showed a filling defect in the base of the bladder, and ultrasound revealed a sessile space-occupying lesion arising from the left bladder wall posteriorly. Flexible and, later, rigid cystoscopy and biopsy demonstrated necrotic slough and debris but no tumour. Ultrasound scan after 2 weeks showed a similar lesion, but ultrasound-guided biopsy was normal with nothing to explain the ultrasound appearances. A follow-up ultrasound scan about 7 weeks later again showed an echogenic mass, but the echogenic mass was seen to move from the left to the right side of the bladder on turning the patient, always maintaining a dependent position. The echogenic bladder mass thus represented a collection of debris, which had accumulated as a result of chronic retention of urine and physical immobility.

CONCLUSION

Recognising the true, non-neoplastic nature of these lesions enabled us to avoid unnecessary surgical procedures in these patients, who were at high risk of surgical complications because of severely compromised cardiac and respiratory function.

Flawed trial of micturition in cervical spinal cord injury patients: guidelines for trial of voiding in men with tetraplegia

STUDY DESIGN

A retrospective study.

OBJECTIVES

(1) To raise awareness of flawed trial of micturition (TOM) in male spinal cord injury (SCI) patients; and (2) to present guidelines for trial of voiding in male SCI patients.

SETTING

Regional Spinal Injuries Centre, Southport, UK.

METHODS

Trial of micturition in male SCI patients refers to discarding indwelling catheters and establishing them on balanced voiding with penile sheath drainage. We describe seven SCI patients, whose trial of micturition was flawed.

RESULTS

Two patients (C-6 and C-4 tetraplegia respectively) developed severe autonomic dysreflexia (headache, sweating, and increase in blood pressure) 2-3 h after removal of urethral catheter. A C-4 tetraplegic developed severe urinary infection after TOM. Four patients with tetraplegia started retaining increasing amounts of urine and developed urinary infections/autonomic dysreflexia/hydronephrosis 1-21 months after they were established on sheath drainage after TOM.

CONCLUSION

During TOM, patients with cervical SCI could develop autonomic dysreflexia, urinary infection, or hold progressively increasing volumes of residual urine. TOM should be guided by videourodynamics. SCI patients need alpha-blockers, and anticholinergics if voiding pressures are >40-50 cm H(2)O. If high urethral resistances are found, sphincterotomy and/or bladder neck incision will help the patients to void by triggering. SCI patients, who had undergone successful TOM, require meticulous follow-up including urodynamics. Intermittent catheterisation without adequate medications based on cystometrogram may be hazardous, and may result in upper tract damage. Facilities for supplementary catheterisation (three to four times a day) should be available in the community if a patient is unable to maintain complete, low-pressure, emptying of bladder.

Treatment of spasticity in a spinal cord-injured patient with intrathecal morphine due to intrathecal baclofen tolerance--a case report and review of literature

STUDY DESIGN

Case report.

OBJECTIVE

To report treatment of spasticity in a spinal cord-injured person with intrathecal morphine after the person developed tolerance to intrathecal baclofen.

METHOD

Spasticity in a 36-year-old man with T6 complete paraplegia was treated with increasing doses of intrathecal baclofen. When he developed tolerance to intrathecal baclofen, he was given continuous infusion of morphine intrathecally.

SETTING

Regional Spinal Injuries Centre, UK.

RESULTS

Spasticity was adequately controlled by intrathecal morphine.

CONCLUSION

In spinal cord-injured patients with severe spasticity, who become tolerant to intrathecal baclofen, treatment with intrathecal morphine may be useful.

Occlusion of left common iliac vein by a distended urinary bladder in a male with paraplegia due to spinal cord injury

STUDY DESIGN

A report of a male subject who sustained paraplegia at T-5 level due to spinal cord injury (SCI) 18 years ago, and in whom, occlusion of the left common iliac vein by a distended bladder was detected during a routine follow-up.

OBJECTIVES

To illustrate a rare complication of chronic distension of the urinary bladder viz occlusion of the left common iliac vein, which persisted even after providing adequate bladder drainage by intermittent catheterisation.

SETTING

Regional Spinal Injuries Centre, Southport, UK.

METHODS

As part of a routine follow-up, we performed intravenous urography by injecting 50 ml of Ultravist 300 in a vein over the dorsum of the left foot. Opacification of collateral veins in the pelvis was seen in the 5- and 10-min films, which suggested iliac venous occlusion. In order to confirm the diagnosis, contrast was injected intravenously in the left foot and venography was performed.

RESULTS

Venography revealed a distended left common iliac vein with contrast flowing into the right internal iliac vein through collateral veins in the pelvis; the right common iliac vein and inferior vena cava were patent. Duplex Doppler sonography showed compression of left common iliac vein by the posterior wall of a distended bladder with absence of blood flow through the compressed segment. Computerised tomography (CT) confirmed the diagnosis of extrinsic compression of the left common iliac vein against the promontory of sacrum by a distended bladder. CT excluded other causes for iliac vein occlusion.

CONCLUSION

In a male subject with SCI, chronic bladder distension produced occlusion of the left common iliac vein. Health professionals caring for individuals with SCI should be aware that long-standing bladder distension could cause pressure effects upon adjacent structures in the pelvis.

Bilateral extracorporeal shock wave lithotripsy in a spinal cord injury patient with a cardiac pacemaker

OBJECTIVES

To review the precautions to be observed before and during extracorporeal shock wave lithotripsy (ESWL) in spinal cord injury (SCI) patients with a cardiac pacemaker and the safety of bilateral ESWL performed on the same day.

DESIGN

A case report of bilateral ESWL in a SCI patient with a permanent cardiac pacemaker.

SETTING

The Regional Spinal Injuries Centre, Southport, the Lithotripsy Unit, the Royal Liverpool University Hospitals NHS Trust, Liverpool, and the Department of Cardiology, Manchester Royal Infirmary, Manchester, UK.

SUBJECT

A 43-year-old male sustained a T-4 fracture and developed paraplegia with a sensory level at T-2. During the post-injury period, he developed episodes of asystole requiring implantation of a dual chamber (DDD) permanent pacemaker. Twenty-one months later, he developed a right ureteric calculus with hydronephrosis. A radio-opaque shadow was seen in the left kidney with no hydronephrosis. During right ureteric stenting, the ureteric stone was pushed into the renal pelvis. 1,500 shock waves were delivered to this stone on the right side, followed by ESWL to the left intra-renal stone with 1250 shock waves.

RESULTS

The patient tolerated ESWL to both kidneys. The pacemaker was reprogrammed to a single chamber ventricular pacing mode at 30 beats per minute with a reduced sensitivity during lithotripsy. There were no untoward cardiac events during or after lithotripsy. The serum creatinine was 45 micromol/l before lithotripsy and 44 micromol/l two weeks after ESWL.

CONCLUSION

SCI patients with a cardiac pacemaker may be able to undergo extracorporeal shock wave lithotripsy following temporary reprogramming of the pacemaker. Bilateral, simultaneous ESWL is safe in the vast majority of patients provided that there is no risk of simultaneous ureteric obstruction by stone fragments. However, it should be remembered that a decrease in renal function could occur following bilateral ESWL of renal calculi.

Xanthogranulomatous funiculitis and epididymo-orchitis in a tetraplegic patient

STUDY DESIGN

A case report of xanthogranulomatous funiculitis and epididymo-orchitis. Xanthogranulomatous inflammation is an uncommon, non-neoplastic process characterised by destruction of tissue, which is replaced by a striking cellular infiltrate of lipid-laden macrophages.

CASE REPORT

A 21-year male sustained complete tetraplegia at C-6 level, after a fall in 1998. The neuropathic bladder was managed with an indwelling urethral catheter. He had many unsuccessful trials of micturition. Sixteen months after the cervical injury, he noticed swelling of the left side of the scrotum following removal of a blocked catheter. He was prescribed antibacterial therapy. Four weeks later, physical examination revealed a hard and irregular swelling encompassing the testis, epididymis and spermatic cord. The clinical diagnosis was epididymo-orchitis progressing to pyocele. Through a scrotal incision, the swollen testis, epididymis and diseased segment of the spermatic cord were removed en masse. Histopathology showed extensive areas of necrosis, with xanthogranulomatous inflammation in the spermatic cord and to a lesser extent in the testis/epididymis.

CONCLUSION

Repeated episodes of high-pressure urinary reflux along the vas deferens during dyssynergic voiding, and subsequent interstitial extravasation of urine together with chronic, low-grade, suppurative infection possibly led to development of xanthogranulomatous inflammation in the testis and the epididymis. Since tissue destruction is a feature of xanthogranulomatous inflammation, the definite and curative treatment is either complete (or, where applicable, partial) excision of the affected organ in most of the cases.

Field trial of efficacy of local compression immobilization first-aid technique in Russell's viper (Daboia russelii siamensis) bite patients

A field trial of efficacy of local compression immobilization first-aid technique in 42 Russell's viper bite cases was studied and only 19 were envenomed. Proper immobilization was carried out in 3/13 immobilized cases. The average time of application of the pad was 1.12 hours (range 5 minutes to 7 hours) and the total duration of the pad application was 3 hours 40 minutes (range 30 minutes to 9 hours). Venom levels measured at the hospital before and at 15 and 30 minutes after release of the pad (n=10) showed a rise of 5 to 30 ng/ml of venom following release. Movement of venom antigen was found to be retarded in all cases (n=9) whose venom levels were measured at 15 and 30 minutes with the pad in place. Sixteen out of 19 cases had systemic envenoming, indicating that pad or immobilization alone is not effective in delaying spread of venom. The incidence of local necrosis 3/42 (8%) following use of the pad was comparable to that of the systemic cases without the pad. No ill effects were observed following its application for as long as 9 hours. Local blackening seen in 4/36 (10%) cases was likely to be result of a local venom effect.

Delayed diaphragm recovery in 12 patients after high cervical spinal cord injury. A retrospective review of the diaphragm status of 107 patients ventilated after acute spinal cord injury

STUDY DESIGN

The functional outcome of the diaphragm after acute spinal cord injury was reviewed over a 16 year period for 107 patients who had required assisted ventilation in the acute phase.

OBJECTIVES

To quantify the incidence of recovery of diaphragm function which occurred beyond the period of acute oedema; to produce a time-related profile of this as a guide to clinicians considering phrenic nerve pacing; and to assess the value of phrenic nerve testing in predicting recovery.

SETTING

The Southport Regional Spinal Injuries Centre, Southport, England.

METHODS

Bilateral phrenic nerve and diaphragm integrity was assessed clinically, by spirometry, and by fluoroscopy without and with phrenic nerve stimulation.

RESULTS

Thirty-one per cent of all the ventilated patients (33 cases), with a level of injury between C1 and C4 (Scale A in ASIA Impairment Scale), had diaphragmatic paralysis at the time of respiratory failure. The subsequent diaphragm recovery which appeared in seven of these patients, between 40 and 393 days (mean 143), permitted weaning from ventilatory support at 93 to 430 days (mean 246) after the acute injury, with a vital capacity of over 15 ml kg(-1) at that stage. The diaphragm recovery in a further five patients, whose vital capacity remained below 10 ml kg(-1) and who could not be fully weaned, occurred significantly later, between 84 and 569 days (mean 290), P=0.053. Negative phrenic nerve tests were followed by weaning at a later interval in several cases. By contrast, one patient with an early positive phrenic stimulation test and subsequent diaphragm activity could not be weaned from the ventilator.

CONCLUSION

Twenty-one per cent of the patients with initial diaphragm paralysis were ultimately able to breathe independently after 4 and 14 months, whilst a further 15% had some diaphragm recovery. Phrenic nerve testing should be repeated at 3 monthly intervals for the first year after high tetraplegia.

A review of the readmissions of patients with tetraplegia to the Regional Spinal Injuries Centre, Southport, United Kingdom, between January 1994 and December 1995

Patients with chronic tetraplegia are prone to develop unique clinical problems which require readmission to specialised centres where the health professionals are trained specifically to diagnose, and treat the diseases afflicting this group of patients. An appraisal of the readmission pattern of tetraplegic patients will provide the necessary data for planning allocation of beds for treatment of chronic tetraplegic patients. Hospital records of patients with tetraplegia readmitted to the Regional Spinal Injuries Centre, Southport, UK between 1 January 1994 and 31 December 1995 were analyzed to find out the number of tetraplegic patients who required readmission, reasons for readmission, duration of hospital stay, and mortality among patients readmitted. During the 2-year period, 155 tetraplegic patients were readmitted and 44 of them (28.4%) required more than one readmission (total readmission episodes: 221); these patients occupied 4.5 beds which is equivalent to 11.5% of the total bed capacity of the spinal unit. Among the reasons for the readmissions, evaluation and care of urinary tract disorders topped the list with 96 readmission episodes (43.43%) involving 70 patients; the median hospital stay was 3 days, and 18 patients (26%) required more than one readmission during this period. One hospital bed was occupied by the tetraplegic patients requiring treatment/evaluation of urinary tract disorders. Assessment and treatment of cardio-respiratory diseases was the second most common reason for readmission with 51 readmission episodes pertaining to 27 patients having a median hospital stay of 6 days; 13 patients (48%) were readmitted more than once within this 2-year period. Treatment of cardio-respiratory diseases in chronic tetraplegic patients required 1.2 hospital beds yearly. Only five tetraplegic patients were readmitted for treatment of pressure sore(s); however they had a prolonged hospital stay (median duration: 101 days). Social reasons accounted for 13 readmission episodes concerning nine patients who stayed in the hospital for varying periods (median: 6.5 days; mean: 35 days). Four tetraplegic patients readmitted with acute chest infection expired. An 81 year-old tetraplegic died of myocardial infarction. Urinary sepsis, renal insufficiency, respiratory failure and intra-cerebral haemorrhage accounted for the demise of a 41 year-old tetraplegic patient following surgical removal of a large, impacted stone at the pelviureteric junction. A tetraplegic patient who was admitted with haematuria subsequently underwent cystectomy for squamous cell carcinoma of the urinary bladder; he developed secondaries and expired 5 months later. As more patients with high cervical spinal cord injury survive the initial period of trauma, and as the life expectancy of tetraplegic patients increases, it is likely that greater numbers of tetraplegic patients will be requiring readmission to spinal injuries centre. Although it may be possible to prevent some of the complications of spinal cord injury and hence the need for a readmission, progress in medicine and rehabilitation technology will create additional demands for readmissions of chronic tetraplegic patients in order to implement the newer therapeutic strategies. Thus a change in the pattern of readmission of chronic tetraplegic patients is likely to be the future trend and this should be taken into account while making plans for providing the optimum care to chronic tetraplegic patients.

Pathophysiology of autonomic dysreflexia: long-term treatment with terazosin in adult and paediatric spinal cord injury patients manifesting recurrent dysreflexic episodes

INTRODUCTION

Spinal cord injury (SCI) results in disruption of synaptic influences on the sympathetic preganglionic neurones. Remodelling of spinal cord circuits takes place in spinal neurones caudal to cord injury. There is an increased vascular alpha-adrenoceptor responsiveness, and peripheral afferent (bladder) stimulation in SCI subjects induces a marked noradrenaline spillover below the level of spinal lesion. These neurophysiological changes possibly contribute to the development of autonomic dysreflexia, a condition of sympathetic hyper-excitability that develops after cervical, or upper dorsal cord injury with resultant paroxysmal rise in arterial pressure, and provide the scientific basis for the use of terazosin, a once-a-day, selective alpha-one adrenergic blocking drug.

OBJECTIVES

The use of terazosin, a long-acting, alpha 1-selective blocking agent was investigated in SCI patients who developed recurrent symptoms of autonomic dysreflexia, eg headache, sweating flushing of the face together with an increase in the arterial pressure.

DESIGN

An open, prospective study of the efficacy of terazosin in controlling recurrent autonomic dysreflexia in traumatic tetraplegic/paraplegic patients manifesting clinical features of dysreflexia in the absence of an acute precipitating cause such as a blocked catheter.

SETTING

The initial assessment and treatment were carried out in the Spinal Injuries Centre. Subsequently, the patients were followed-up in the community. They were monitored by telephonic interviews, follow-up visits by the patients to the hospital, and home-visits by the staff of the spinal unit.

SUBJECTS

Eighteen adults with tetraplegia (female: 1; male: 17), three children with ventilator-dependent tetraplegia and three adult male patients with paraplegia who exhibited recurrent features of autonomic dysreflexia in the absence of an acute predisposing factor for dysreflexia eg performance of an invasive procedure such as cystoscopy, digital evacuation of bowels, or acute urinary retention, were enrolled in this study.

INTERVENTION

After discussion with the patients and their carers, terazosin was prescribed with a starting dose of 1 mg in an adult and 0.5 mg in a child administered nocte. The patients were observed for (1) drug-induced hypotension; (2) clinical symptoms due to side effects of terazosin; and (3) continued occurrence of dysreflexic symptoms. Step-wise increments of the dose of terazosin (1 mg in case of adults, and 0.5 mg in a child) was carried out at intervals of 3-4 days, if a patient continued to develop dysreflexia but did not manifest any serious side effect.

OUTCOME MEASURES

Complete subsidence of dysreflexic symptoms, or development of an adverse event necessitating termination of the terazosin therapy was the clinical end point.

RESULTS

The dysreflexic symptoms subsided completely with the terazosin therapy in all the patients. The twenty-one adult patients required a dose varying from 1-10 mg, whereas the paediatric patients required only 1-2 mg of terazosin. The side effects of postural hypotension and drowsiness were transient, and mild. One tetraplegic patient developed persistent dizziness and therefore, the drug therapy was discontinued.

CONCLUSION

In 21 adult and three paediatric spinal cord injury patients manifesting recurrent episodes of autonomic dysreflexia in the absence of an acute predisposing cause, the use of terazosin, a once-a-day, specific alpha-one blocker resulted in complete subsidence of the dysreflexic symptoms. However, one tetraplegic patient required termination of terazosin therapy because of persistent dizziness.

The use of personal protective measures in control of malaria in a defined community

Malaria is one of the main health problems in the non-immune immigrant workers and army personnel of the malaria endemic areas in Myanmar. Due to changes in the vector bionomics and multiresistant strains of P. falciparum, chemoprophylaxis alone is not an effective means of control of malaria in them. So it is envisaged that the combined used of personal protective measures (deltamethrin impregnated bed-nets, scalves and hand-bands) and the chemoprophylaxis will be an effective means of control of malaria in the define group of people. The study also intended to find out the side effects of the deltamethrin and feasibility and acceptability of methods by the users. The study was conducted in Theini Township, Northern Shan State, from March to November 1993. The study population consisted of all ages of both sexes 554 and 440 persons in the test and control groups respectively. At the initial phase of the study, malaria infected persons from both the groups were treated. The experimental group received personal protective measures with impregnation of bed-nets using 25 mg ai/m2 of deltamethrin at 4 monthly intervals and the scarves and hand-bands at twice the concentration of the insecticides at monthly intervals. Chemoprophylaxis was given to both the groups at weekly intervals using age adjusted dosage of Pyrixine tablet (sulfadoxine-pyrimethamine). The parasitological, entomological, and epidemiological indices were collected at two month intervals in both the groups. The study clearly showed the impact of personal protective measures and chemoprophylaxis on malaria infection in the studied subjects. During the study period, the out patient malaria cases of the test group was 6% to 11.2% and that of the control group was 12% to 21.6% in Theini Hospital. The reinfection rate of the test group (0.9 to 4.7%) was also significantly lower than the control group (6.1 to 14.3%) from July to November. Acceptance of the treated bed-nets, scarves and hand-bands was high and good compliance was found in the follow up. The results of the study clearly showed that malaria can be controlled effectively in the defined group of persons for a malaria transmission season by using chemoprophylaxis and personal protective measures.