The SAGES Bariatric Surgery Outcome Initiative

BACKGROUND

The recent initiative for identifying centers of excellence in bariatric surgery calls for documentation of surgical outcomes. The SAGES Outcomes Initiative is a national database introduced in 1999 as a method for surgeons to accumulate and compare their data with summary national data. A bariatric-specific dataset was established later in 2001. The aim of this study was to compare the outcomes of bariatric surgery from the Society of American Gastrointestinal Endoscopic Surgeons' (SAGES) bariatric database with data derived from a national administrative database of academic centers.

METHODS

Between 2001 and 2004, 24 surgeons with 1,954 patients participated in the SAGES Bariatric Outcome Initiative, and 97 institutions with 42,847 patients participated in the University HealthSystem Consortium (UHC) database. Only 7 of the 24 surgeons participating in the SAGES Bariatric Outcome Initiative submitted more than 50 cases. The main outcome measures included demographics, comorbidities, type of bariatric procedure, operative time, length of hospital stay, short- and long-term complications, mortality, and weight loss.

RESULTS

Both datasets were comparable for gender. Roux-en-Y gastric bypass had been performed for 88% of the patients in the SAGES database and 96% of the patients in the UHC database. Associated comorbidities were similar between the two groups except for a higher rate of hyperlipidemia for the patients in the SAGES database. The SAGES database contains more bariatric-specific information such as body mass index, operative time, blood loss, bariatric-specific complications, long-term complications, and weight loss data than the UHC database. According to the available data, no statistically significant differences exist between the two datasets in terms of perioperative complications and mortality.

CONCLUSIONS

The SAGES Bariatric Outcome Initiative provides valuable bariatric-specific data not currently available in an administrative database that may be useful for benchmarking purposes. However, this database is currently underutilized.

Emergency medical services in Islamabad, Pakistan: a public-private partnership

OBJECTIVES

The objective of this study was to evaluate the emergency medical services (EMS) based in Islamabad, Pakistan. Rescue-15 is an innovative EMS collaboration project between the police, the private sector and the community.

METHODS

Data from Rescue-15 were used for systems analysis. The institutional set-up, private-public partnership, client satisfaction and sustainability issues were examined. The access and efficiency of EMS were assessed in terms of ambulance response time.

RESULTS

Primarily, systems analysis showed community participation to explain the project's strength. Since its establishment, the project has been meeting its own recurrent expenditures without levying an extra burden on the Government. Sustainability issues such as amendments to legislation have been addressed at departmental and governmental levels. Data analysis showed that rescue time is, on average, 10.4 min (SD=2.6 min). A client survey also demonstrated user satisfaction and increased confidence in the service.

CONCLUSIONS

This EMS programme exemplifies the potential of public-private partnership involving the police and the private sector in project implementation and management in a developing country with scarce resources. This initiative to involve the public and the private sector may provide a model for implementation of such services in other resource-poor developing countries, which may in turn facilitate realistic solutions for better prehospital care in developing countries.

Illness incidence and health seeking behaviour among street children in Rawalpindi and Islamabad, Pakistan - a qualitative study

BACKGROUND

This is the first study in Pakistan to elicit street children's perceptions of health and the barriers to service utilization.

METHODS

A descriptive, cross-sectional study was carried out during September and October 2000. The data were collected in twin-cities of Rawalpindi and Islamabad through individual, semi-structured street-based interviews; with 40 school age participants; in addition, three focus group discussions were also completed. The sampling was convenience based. This strategy was applied because of the non-existence of a sampling frame for the street-based children owing to the absence of any census or other reports, and also the difficulty of tracking very mobile street children.

RESULTS

Results indicate that these youth were highly susceptible to many adverse health outcomes. The common ailments were injuries, respiratory and skin infections. Along with low self-perceived severity of medical problems, self-medication was preferred and medical pluralism existed. Their perceived constraints to services included long waiting time, monetary, negative attitude of service providers and their inferior status.

CONCLUSIONS

In developing user-friendly services, it is important to be sensitive to street children's needs and requirements. Eliminating these barriers and the integration of health services among public and private resources are imperative for the regular and sustainable provision of health care to this vulnerable, under-served group of children.

Emergency obstetric care in Pakistan: Potential for reduced maternal mortality through improved basic EmOC facilities, services, and access

OBJECTIVE

To ascertain and compare compliance with UN emergency obstetric care (EmOC) recommendations by public health care centers in Pakistan's Punjab and Northwest Frontier Province (NWFP) provinces.

METHOD

Cross-sectional data were collected from July through September 2003 using UN process indicators. From each province, 30% of districts (n=19); were randomly selected; all public health facilities providing EmOC services (n=170) were included.

RESULTS

The study found that out of 170 facilities only 22 were providing basic and 37 comprehensive EmOC services in the areas studied. Only 5.7% of births occurred in EmOC health facilities. Met need was 9% and 0.5% of women gave birth by cesarean section. The case fatality rate was a low 0.7%, probably due to poor record keeping. Access and several indicators were better in NWFP than in Punjab.

CONCLUSION

Almost all indicators were below UN recommendations. Health policy makers and planners must take immediate, appropriate measures at district and hospital levels to reduce maternal mortality.

Effect of aqueous extract of Pterocarpus marsupium wood on alloxan-induced diabetic rats

An aqueous extract of Pterocarpus marsupium wood was screened for hypoglycemic activity on alloxan-induced diabetic rats. During both acute and sub-acute tests, the water extract, at an oral dose of 250 mg/kg, showed statistically significant hypoglycemic activity.

A second locus for Aicardi-Goutieres syndrome at chromosome 13q14-21

BACKGROUND

Aicardi-Goutières syndrome (AGS) is an autosomal recessive, early onset encephalopathy characterised by calcification of the basal ganglia, chronic cerebrospinal fluid lymphocytosis, and negative serological investigations for common prenatal infections. AGS may result from a perturbation of interferon alpha metabolism. The disorder is genetically heterogeneous with approximately 50% of families mapping to the first known locus at 3p21 (AGS1).

METHODS

A genome-wide scan was performed in 10 families with a clinical diagnosis of AGS in whom linkage to AGS1 had been excluded. Higher density genotyping in regions of interest was also undertaken using the 10 mapping pedigrees and seven additional AGS families.

RESULTS

Our results demonstrate significant linkage to a second AGS locus (AGS2) at chromosome 13q14-21 with a maximum multipoint heterogeneity logarithm of the odds (LOD) score of 5.75 at D13S768. The AGS2 locus lies within a 4.7 cM region as defined by a 1 LOD-unit support interval.

CONCLUSIONS

We have identified a second AGS disease locus and at least one further locus. As in a number of other conditions, genetic heterogeneity represents a significant obstacle to gene identification in AGS. The localisation of AGS2 represents an important step in this process.

Men and reproductive health in rural Pakistan: the case for increased male participation

OBJECTIVES

In Pakistan, the role of men has always been considered to dominate in the decision-making process pertaining to women's fertility and birth spacing. This study was done to explore men's knowledge, perceptions and behavior on various reproductive health issues.

METHODS

A cross-sectional survey was carried out among 180 married adult males in 12 rural districts of Pakistan in 2000. The study was qualitative, utilizing tools such as in-depth and key-informant interviews.

RESULTS

The findings pointed out gaps in knowledge and misconceptions among men on a range of reproductive health issues and stress the need for health education. The findings suggest that strategies such as couple counseling, door-to-door campaigns by village-based male family planning workers and small group meetings could be effective. This study indicates a pressing need for incorporating effective intervention strategies, both at the community and the clinic level, backed with efficient counseling, motivation, and provision of services with appropriate education of males in rural areas.

CONCLUSION

The findings suggest that investment into promotion of healthy fertility control practices among men will be effective in the near future, as they are interested in acquiring new knowledge and are willing to become partners.

Genetic syndromes mimic congenital infections

Genetic syndromes that mimic congenital infection are important to recognize because of the associated risk of recurrence. We describe two brothers born to consanguineous parents with clinical features suggestive of intrauterine infection but with negative serologic investigations. Our observations suggest that Aicardi-Goutieres syndrome (AGS) and pseudo-TORCH syndrome likely represent the same disorder.

Asymptomatic lymphangitis carcinomatosis due to squamous cell lung carcinoma

Lymphangitis carcinomatosa most commonly due to primary malignancy originating in the breast, stomach, pleura and prostate but may also originate from the lung itself. It is clinically characterised by progressing dyspnoea with or without cough even at an early stage. We report the case of a patient with squamous cell lung cancer presenting with asymptomatic lymphangitis carcinomatosa.

Co-existence of lichen planus and sarcoidosis

We present a 53-year-old patient with respiratory sarcoidosis who subsequently developed cutaneous lichen planus (LP). Biopsy of the skin lesions showed typical LP with no evidence of sarcoid granulomas. To the best of our knowledge the two conditions have not been reported in association.

New compounds from the seeds of Embelia ribes Burm

Phytochemical investigation of the seeds of Embelia ribes Burm. resulted in the isolation of three new compounds identified as 3-(4"-hydroxyoctadecanyloxy)-p-quinonyl-5-methylene-8-(10-pentanyloxy)-p-quinone (embelinol) (1), n-pentacosanyl-n-nonadeca-7'-en-9'-alpha-ol-1'-oate (embeliaribyl ester) (2) and 1,2,4,5-tetrahydroxy 3-undecanyl benzene (embeliol) (3) along with the known compound 2,5-dihydroxy-3-undecyl-2,5-cyclohexadiene-1,4-dione (embelin) (4). Their structures have been established on the basis of spectral data analyses and chemical reactions.

Socio-economic status of chronic arsenicosis patients in Bangladesh

The study showed that the maximum number of arsenicosis patients (71%) belonged to low income group and 29% belong to middle class income group but none was found in high income group and all these patients were from rural areas of the country. Majority of all these patients was related with the traditional occupation of the country like cultivation (53%) in addition to lower level of educational background (81.5%). Most of the patients of chronic arsenicosis were suffering from malnutrition (91%). The present study which reflects that the vast majority of patients of chronic arsenicosis in the country belonged to low income group, but also to low educational background and individuals, who had been suffering from malnutrition, needs a special consideration in the management of the problem. Emphasis has been given to have access to arsenic-free water and protein rich diet to people of arsenic affected areas.

Mutation and polymorphism analysis of TSC1 and TSC2 genes in Indian patients with tuberous sclerosis complex

OBJECTIVE

To find the mutation and polymorphism spectrum of TSC1 and TSC2 genes in patients affected with tuberous sclerosis complex from the Indian population.

MATERIAL AND METHODS

All coding exons and promoter regions of both TSC genes were screened for mutations and polymorphisms in 24 TSC families using polymerase chain reaction-single strand conformation polymorphism and DNA sequencing techniques.

RESULTS

A single previously known mutation, c.2111_2112delAT was identified in the TSC1 gene. A total of 11 mutations were identified in the TSC2 gene. Of these, seven mutations, c.137_138delGA, c.2070delC, c.2087_2088insAA, c.3080T>C (p.L1027P), c.648+1G>A, c.3131+1G>A and c.5034C>G were novel. The remaining four mutations, c.4544_4547delACAA, c.1941_1942insT, c.1831C>T (p.R611W) and c.1832G>A (p.R611Q) had been reported previously in other populations. The novel mutation, c.137_138delGA was predicted to result in the production of a very small tuberin protein of 64 amino acids lacking all seven functional domains. In addition, we also detected three and 10 polymorphisms in the TSC1 and TSC2 genes respectively. DNA sequence analysis of promoter regions of both TSC genes in 24 families did not show any variation.

CONCLUSIONS

This is the first molecular genetic study of TSC in an Indian population. A total of 12 mutations were detected in 24 Indian TSC families in TSC genes. All except one mutation were detected in the TSC2 gene. No variation was found in the promoter regions of either gene. As observed in the western and Japanese populations, the mutations were scattered across the TSC2 gene.

Effect of aqueous extract of Cyamopsis tetragonoloba Linn. beans on blood glucose level in normal and alloxan-induced diabetic rats

Effect of feeding orally the aqueous extract of beans of Cyamopsis tetragonoloba was investigated on fasting blood glucose levels in glucose loaded, normal and alloxan-induced diabetic rats and compared with gliclazide, a reference drug. The aqueous extract of beans at 250 mg/kg body wt significantly lowered blood glucose levels in alloxan-induced diabetic rats within 3 hr of administration. Continued administration of the extract at the same dose daily for 10 days produced statistically significant reduction in the blood glucose levels while marginal activity was seen in normal and glucose-loaded rats.

Factors influencing the results of surgery for hypospadias: experience at NICH

OBJECTIVE

To evaluate the factors that may influence the results of surgery after hypospadias repair at National Institute of Child Health, Karachi.

METHODS

It was a retrospective observational study. Files of all patients who had Hypospadias repair were retrieved and analysed with a view to identify the factors which may influence the results of surgery for Hypospadias. Patients with complete record available were included in the study, whereas those with incomplete data were excluded. For most patients who had penile or distal hypospadias TIP (Tubularised Incised Plate) urethroplasty was performed. Patients with severe chordee had Duckett Island flap urethroplasty as a two stage procedure. Patients having moderate chordee were subjected to the Mustardee Procedure. Some underwent MAGPI and Mathieu's repairs.

RESULTS

One hundred four patients were operated. Files of only 46 patients with a mean age of 4 years could be retrieved and these were included in the study. Twenty five patients had TIP urethroplasty, 5 had island flap urethroplasty, 2 had Mustardee repair, 6 had MAGPI, 5 had Mathew's repair and 3 had Byers Staged Urethroplasty. Over all incidence of fistula formation was 26%. The frequency of fistula formation was less with TIP urethroplasty (16%) compared to those who received no dartos pedicle flap. Mathieu's repair gave good results with 20% incidence of fistula formation. Highest numbers of complications (60%) were seen in patients who had Island flap urethroplasty for proximal hypospadias with chordee.

CONCLUSION

TIP urethroplasty is a safe and reliable method of hypospadias repair. The results of surgery can however be improved by using dartos pedicle flap to protect the repair, meticulous surgical techniques, use of monofilamentous absorbable suture material and soft waterproof dressing.

Homologous transplantation of the mitral valve: a review

Numerous experimental studies were conducted on homologous transplantation of the mitral valve either for mitral or tricuspid valve replacement in the early '60s. The first mitral homograft in humans was performed in 1965 by Senning. Since that time, there has been a limited number of implants mainly because of technical difficulties related to the insertion of the papillary muscles. Based on principles established for mitral valve repair, a reproducible method of homograft replacement of the mitral valve was described. Following validation in animals, the technique was applied in a series of 104 patients undergoing partial or complete mitral valve replacement. Significant improvements concerned: selection of indications and contraindications, staged approach according to the extent of the lesions leading either to partial or total replacement, systematic use of prosthetic ring annuloplasty, understanding of papillary muscle anatomy allowing a rationale for a reliable attachment method. In hospital mortality was 3.8%. At 8 years, the incidences of patients free from cardiac death and from all death were 90.6% and 82% respectively. Freedom from any cardiac event (death or reoperation) was 72% at 7 years. Similarly to the aortic homograft, mitral homograft durability was decreased in younger patients. Partial homograft replacementoffered satisfactory results particularly in the case of endocarditis and enhanced the possibilities of valve repair. The limitations of the technique are: the technical difficulty which does not permit a completely standardized operation, the risk of early valve dysfunction related to valve mismatch and the risk of late deterioration mainly leading to stenosis. Homologous transplantation of the mitral valve was also applied for tricuspid valve replacement in the case of infective endocarditis or for replacement of a degenerated bioprosthesis. Satisfactory results have been reported. However due to the lack of anatomical landmarks, the implantation procedure has remained technically challenging. Thus until further progress demonstrates a clear superiority of the mitral homograft, bioprosthesis remains the gold standard for replacing the mitral or the tricuspid valve with a biological substitute.

Diabetic nephropathy as a cause of end-stage renal disease in Egypt: a six-year study

The prevalence of diabetic nephropathy as a cause of end-stage renal disease [ESRD] in Egypt has been examined in small cross-sectional studies, with conflicting results. The need for a large-scale study prompted us to perform this 6-year multiple cross-sectional study. A sample of ESRD patients enrolled in the Egyptian renal data system was evaluated during the period 1996-2001 for the prevalence of diabetic nephropathy. Prevalence gradually increased from 8.9% in 1996, to 14.5% in 2001. The mean age of patients with diabetic nephropathy was significantly higher than that of patients with ESRD from other causes. Mortality was also significantly higher in diabetic patients with ESRD

Effect of water extract of Psidium guajava leaves on alloxan-induced diabetic rats

A water extract of Psidium guajava leaves was screened for hypoglycemic activity on alloxan-induced diabetic rats. In both acute and sub-acute tests, the water extract, at an oral dose of 250 mg/kg, showed statistically significant hypoglycemic activity.

Congenital glaucoma and brain stem atrophy as features of Aicardi-Goutières syndrome

We report on three children from two families with Aicardi-Goutières syndrome. All three had congenital glaucoma. Additionally, neuroimaging demonstrated significant brain stem atrophy in the affected sib-pair. These features have not been previously described in Aicardi-Goutières syndrome and expand the phenotypic spectrum.

Flexural Bazex syndrome associated with tonsillar adenocarcinoma

Bazex Syndrome (acrokeratosis paraneoplastica) is characterized by a psoriasiform skin eruption that favors acral sites and has been associated with underlying malignancy in all reported cases. Squamous cell carcinoma of the upper third of the respiratory system and upper third of the gastrointestinal tract and squamous cell carcinoma of unknown primary with cervical lymph node metastasis are the most commonly associated neoplasms. Here we report a case of flexural Bazex syndrome with tonsillar adenocarcinoma.