The changing epidemiology of the bronchiolitis epidemic in Tallaght Hospital

Bronchiolitis affects one third of babies in their first year of life. We investigated all bronchiolitis admissions to Tallaght Hospital in the last five years, with the hope of providing an insight into the epidemic in an Irish population. We analysed these 1,202 admissions on the basis of time of year (busiest being December at 24.20%), length of stay (mean 2.92 days), gender (62% male) and age (mean 30.29 weeks). There was a 102% increase in the average incidence of bronchiolitis in the first six months of 2011 and 2012 (186) compared to the previous four years (92.25). P value was statistically significant at 0.0469. Our findings were backed up by comparable data from OLCH, Crumlin (149.5 for 2011-2012 vs 36.25 for 2007-2010). There has been in a significant shift in the timing and incidence of bronchiolitis in Tallaght Hospital in the last two years. We explored the possible reasons for this, with special attention to RSV incidence, climate causes and vaccine programs.

Tumor necrosis factor-α and -β genetic polymorphisms as a risk factor in Saudi patients with vitiligo

Vitiligo is an acquired depigmentary disorder of the skin, characterized by multiple susceptibility loci and genetic heterogeneity. The etiology of vitiligo is unknown but several hypotheses, including an autoimmune origin, have been proposed. Tumor necrosis factor (TNF)-α, a pleiotropic proinflammatory cytokine, has been shown to play a critical role in several autoimmune diseases including vitiligo. The aim of present study was to determine the association of TNF-α and -β gene polymorphisms with vitiligo in Saudi patients. TNF-α and -β genes were amplified in 123 Saudi patients and 200 matched controls using polymerase chain reaction to search for polymorphisms involved at positions -308, and intron 1 +252. The frequency of the TNF-α (-308) GA genotype was higher and the frequencies of the GG and AA genotypes were significantly lower in vitiligo patients compared to controls. These findings suggested that genotype GA-positive individuals at position -308 of TNF-α are susceptible to vitiligo, whereas the GG and AA genotypes might exert a protective effect. The frequency of allele A (TNF-α 2-allele) was significantly higher and that of allele G (TNF-α 1-allele) was lower in vitiligo patients compared to controls, indicating an association of allele A with susceptibility to vitiligo in Saudi patients. The results of our examination of TNF-β (intron 1 +252) polymorphisms showed a significant increase in the frequency of the GG genotype and allele G (TNF-β 1-allele) in vitiligo patients, suggesting a susceptibility of the GG genotype and allele G for vitiligo. By contrast, the high frequency of the GA genotype in controls might indicate a protective effect. The results of the present study strongly support a link between TNF-α (-308) and -β (intron 1 +252) polymorphisms and vitiligo in Saudi patients.

Shifts in the temperature of maximum density (TMD) of ionic liquid aqueous solutions

This work investigates for the first time shifts in the temperature of maximum density (TMD) of water caused by ionic liquid solutes. A vast amount of high-precision volumetric data--more than 6000 equilibrated (static) high-precision density determination corresponding to ∼90 distinct ionic liquid aqueous solutions of 28 different types of ionic liquid--allowed us to analyze the TMD shifts for different homologous series or similar sets of ionic solutes and explain the overall effects in terms of hydrophobic, electrostatic and hydrogen-bonding contributions. The differences between the observed TMD shifts in the -2 < t/°C < 4 range and salting-in or salting-out effects produced by the same type of ions in aqueous solutions at higher temperatures are discussed taking into account the different types of possible solute-water interactions that can modify the structure of the aqueous phase. The results also reveal different insights concerning the nature of the ions that constitute typical ionic liquids and are consistent with previous results that established hydrophobic and hydrophilic scales for ionic liquid ions based on their specific interactions with water and other probe molecules.

Effectiveness of educational interventions in improving clinical competence of residents in an internal medicine residency program in Pakistan

INTRODUCTION

Medical education is a continuously evolving field. Training institutes and programs should have a process in place to gather continuous feedback and then make appropriate modifications in order to provide education and training effectively. Our study aimed to assess the effect of a quality improvement cycle approach in using various educational interventions within a residency. Effects were measured on the key educational outcomes of residents; medical knowledge, skills and professional attitudes using results of postgraduate examination with both written and clinical skills components.

METHODOLOGY

A number of educational interventions were implemented which included changes in work hours with increased time for self-study, new educational activities including a Residents Hour, a Residents Slide Session, Grand Rounds and Journal Clubs, Clinico-pathological conferences, and a two- week postgraduate course for senior residents. Newer and improved assessment tools were also implemented, including an annual in-training mock exam based on the format of the postgraduate examination. Pass rates in postgraduate examinations (Fellow of College of Physicians and Surgeons exam and Member of Royal College of Physicians exam) were compared before and after the interventions to assess the effectiveness of the interventions.

RESULTS

The first group of residents after introduction of the educational interventions completed residency training in 2001. Postgraduate exam pass rates (sometimes after two or more attempts) were 59.2% (42 of 71 graduates) before 2001 and 86.4% (38 of 44 graduates after 2001 (p = 0.002). The number of candidates passing the examinations in either their first or second attempts before 2001 was 17 of 42 (40.5%), which increased to 33 of 38 (86.8%) after 2001 (p = <0.001).

CONCLUSIONS

Our study describes a number of interventions that were successful in bringing about an improvement in the performance of our residents. These can serve as a guide for postgraduate training programs, particularly those of Internal Medicine, in implementing strategies to strengthen training and enhance the performance of trainees.

Medical mortality in Pakistan: experience at a tertiary care hospital

AIM

To acquire systematic data on the causes of hospital mortality in Pakistan, a developing country with scant mortality records.

STUDY DESIGN

Retrospective review of death certificates and hospital charts of patients dying on general and specialty medical services at our hospital during one calendar year.

RESULTS

Of a total 10,590 admissions, 657 (6.2%) died in hospital. The deceased included 357 (54.4%) males and 299 (45.6%) females, with a collective median age of 63 years and mean length of stay 6.71 days (median 4 days, range 1-56 days). Primary cause of death was categorised as infectious (21.2%), pulmonary (17.2%), cancer related (15.7%), cardiovascular (12.6%), gastrointestinal and hepatic (10.8%), neurological (11.4%) and miscellaneous (11.1%). Within each category, the most common diagnoses were septicaemia (76.9% of infectious cases), pneumonia (55.7% of pulmonary cases), myocardial infarction (40.9% of cardiovascular), intracranial haemorrhage (37.3% of neurological), and cirrhosis (45.0% of gastrointestinal). There were multiple causes among malignant disorders with no single cause dominating. Patients with cardiovascular and pulmonary deaths tended to be older than the median age (p = 0.001), while patients with gastrointestinal and cancer related deaths tended to be younger than the median age (p = 0.001). Length of stay did not differ significantly among the various subgroups. About a quarter (26.4%) deaths occurred within 24 h of admission.

CONCLUSIONS

Infections, including septicaemia and pneumonia, are the leading causes of hospital mortality in our setting, followed by malignancy and cardiovascular causes. The overall mortality rate is comparable to published mortality data from other hospital settings.

Mutations in the P2RY5 gene underlie autosomal recessive hypotrichosis in 13 Pakistani families

BACKGROUND

Autosomal recessive hypotrichosis is a rare genetic irreversible hair loss characterized by sparse scalp hair, sparse to absent eyebrows and eyelashes, and sparse axillary and body hair. Affected male individuals have normal beard hair.

OBJECTIVES

To search for pathogenic mutations in the human P2RY5 gene in Pakistani families with autosomal recessive hereditary hypotrichosis.

METHODS

In the present report, 16 unrelated consanguineous Pakistani families having multiple affected individuals with autosomal recessive hypotrichosis were investigated. Linkage in these families was searched by genotyping microsatellite markers linked to autosomal recessive hypotrichosis loci LAH1, LAH2 and LAH3. Thirteen of the families showed linkage to the LAH3 locus on chromosome 13q14.11-q21.32. These families were then subjected to direct sequencing of the P2RY5 gene, which encodes a G protein-coupled receptor.

RESULTS

Sequence analysis of the P2RY5 gene revealed two novel missense mutations (c.742A>T; p.N248Y and c.830C>T; p.L277P) in three families. Five previously described mutations including three missense (c.188A>T; p.D63V, c.436G>A; p.G146R, c.562A>T; p.I188F), one insertion (c.69insCATG; p.24insHfsX52) and one complex deletion (c.172-175delAACT; 177delG; p.N58-L59delinsCfsX88) were detected in the other 10 families.

CONCLUSIONS

Mutations revealed in the present study extend the body of evidence implicating the P2RY5 gene in the pathogenesis of human hereditary hair loss.

Mutation in the HPGD gene encoding NAD+ dependent 15-hydroxyprostaglandin dehydrogenase underlies isolated congenital nail clubbing (ICNC)

BACKGROUND

Isolated congenital nail clubbing (ICNC) is a rare autosomal recessive disorder characterised by enlargement of the terminal segments of fingers and toes with thickened nails due to proliferation of the connective tissues and abnormal function of the nail matrix. In the present study, we investigated a large Pakistani family with 11 affected individuals having hereditary congenital nail clubbing as a single invariable clinical feature without any associated ectodermal, skeletal or systemic imperfection.

OBJECTIVE

To identify a gene underlying the ICNC phenotype.

METHODS

A genome wide homozygosity linkage mapping strategy was used to identify the gene causing ICNC. DNA sequencing was performed to screen 10 candidate genes located in the linkage interval.

RESULTS

We assigned the disease locus for the ICNC to a 13.25 cM region on chromosome 4q32.3-q34.1. This region corresponds to 12.27 Mbp according to the sequence based physical map (Build 36.1) and flanked by markers D4S2952 and D4S415. A maximum two point LOD score of 2.98 ( theta= 0.00) was obtained at marker D4S2368 while a maximum multipoint LOD score of 3.62 was obtained with several markers along the disease interval. Sequence analysis of the candidate genes, in the ICNC linkage interval, revealed a homozygous missense mutation (c.577T>C; p.S193P) in exon 6 of the human HPGD gene encoding NAD(+) dependent 15-hydroxyprostaglandin dehydrogenase (15-PGDH).

CONCLUSIONS

The involvement of 15-PGDH in the pathogenesis of ICNC may open up interesting perspectives into the function of this enzyme in nail morphogenesis/development.