Malaria on the Move : Ecological Considerations for the Armed Forces

BACKGROUND

Armed forces personnel deployed in the North Eastern states of India are vulnerable to falciparum malaria. This vulnerability increases during mobilization of troops.

METHODS

Epidemiological case sheet was used for recording individual movement, clinical features and laboratory investigations of each case of malaria. Immunochromotography test (ICT) or Paracheck Pf was used as a rapid test for falciparum malaria at the regimental aid post (RAP). Subsequently, a case control approach was used to ascertain whether the cases of malaria differed significantly from healthy controls in observing antimalaria measures such as the use of mosquito nets, repellants and chemoprophylaxis.

RESULT

Nineteen out of 623 soldiers suffered from falciparum malaria during a short period of ten days during operational mobilization. Use of mosquito nets and repellants was significantly less among the cases as compared to healthy controls. There was no significant difference among the two groups regarding compliance with chemoprophylaxis.

CONCLUSION

A paradigm of "malaria on the move" or "operational malaria" has been proposed.

Adult hepatoblastoma in a female Down's

Hepatoblastoma is most common primary malignant hepatic neoplasm in children. Median age at diagnosis is one year and mostly present by three years. This is a rare case report of a seventeen years female with Down's Syndrome presented with hepatomegaly diagnosed as hepatoblastoma.

Determining the proximal extent of ulcerative colitis: white cell scan correlates well with histological assessment

BACKGROUND

Assessing the extent of ulcerative colitis determines therapeutic strategies and provides prognostic information. Colonoscopy with mucosal biopsy is considered unsafe in patients with severe disease.

AIM

To assess the correlation between proximal extent of ulcerative colitis as determined by Technitium-99-m hexamethylpropylene amine oxime labelled leucocyte scan (white cell scan) with that determined by histological assessment.

METHODS

One hundred and thirty-five patients, with histologically-confirmed ulcerative colitis, who had a white cell scan and histological assessment of colonic inflammation within 6 months of each other, during the years 1991-2004, were included. Overall agreement, quadratic-weighted kappa (kappa) and polychoric correlations (rho) were calculated to estimate the inter-rater reliability.

RESULTS

The correlation between white cell scan and histological extent was excellent (kappa = 0.7 rho = 0.8). Macroscopic appearance on colonoscopy did not correlate as well with histological extent (kappa = 0.62 and rho = 0.67). White cell scans correlated significantly better in patients with extensive disease (P = 0.02). Colonoscopy predicted disease extent more accurately in patients with limited colitis (P = 0.002).

CONCLUSIONS

Proximal extent of ulcerative colitis determined by white cell scans correlates well with histological assessment especially in patients with more extensive disease. White cell scans offer a reasonable alternative to colonoscopy with mucosal biopsies in determining the proximal extent of colitis.

Time-correlated single-photon counting fluorescence lifetime confocal imaging of decayed and sound dental structures with a white-light supercontinuum source

We report the demonstration of time-correlated single-photon counting (TCSPC) fluorescence lifetime imaging (FLIM) to ex vivo decayed and healthy dentinal tooth structures, using a white-light supercontinuum excitation source. By using a 100 fs-pulsed Ti:Sapphire laser with a low-frequency chirp to pump a 30-cm long section of photonic crystal fibre, a ps-pulsed white-light supercontinuum was created. Optical bandpass interference filters were then applied to this broad-bandwidth source to select the 488-nm excitation wavelength required to perform TCSPC FLIM of dental structures. Decayed dentine showed significantly shorter lifetimes, discriminating it from healthy tissue and hard, stained and thus affected but non-infected material. The white-light generation source provides a flexible method of producing variable-bandwidth visible and ps-pulsed light for TCSPC FLIM. The results from the dental tissue indicate a potential method of discriminating diseased tissue from sound, but stained tissue, which could be of crucial importance in limiting tissue resection during preparation for clinical restorations.

Predominance of hepatitis B virus genotype C among Karens, the 'old settlers' of Andaman and Nicobar Islands, India

The Karens, or 'old settlers', migrated from Myanmar to Andaman and Nicobar islands 80 years ago. A high HBV exposure rate among them has been reported. A study of 34 HBsAg carriers was done to investigate the origin of HBV infection among the Karens. RFLP-based genotyping was confirmed by sequencing and phylogenetic analysis. The predominance of HBV/C1/Cs suggests that they carried HBV during their migration, retained it, and in addition, acquired HBV/D2 from the people of mainland India. The reported association of HBV genotype C with disease severity thus warrants further epidemiological investigations among them and on possible spread among neighboring settlers.

Vaccinations de l'enfant voyageur

Each year, half a million of children leave France to travel towards countries south or east of the European Union, sometimes in poor sanitary conditions. In order to propose essential or useful immunizations for these trips, the current synthesis will allow the practitioner to insure that the routine French immunization schedule has been followed, and to complete it if needed, to protect the child according to the epidemiological situation in the visited area, to try to reduce the limitations of the immunization of the traveler child. In case of emergency, or close departure, it may be useful to follow an accelerated schedule of the last minute, and, sometimes, to immunize traveler children with a chronic disease. Informations on Internet sites useful for the knowledge of current infectious risks in the destination country are also provided.

Homeopathic Arnica montana for post-tonsillectomy analgesia: a randomised placebo control trial

OBJECTIVE

To evaluate the efficacy of Homeopathic Arnica in reducing the morbidity following tonsillectomy.

METHODS

Randomised double blind, placebo controlled trial at a tertiary referral centre. 190 patients over the age of 18 undergoing tonsillectomy were randomised into intervention and control groups receiving either Arnica 30c or identical placebo, 2 tablets 6 times in the first post-operative day and then 2 tablets twice a day for the next 7 days. The primary outcome measure was the change in pain scores (visual analogue scale) recorded by the patient on a questionnaire over 14 days post-operatively; Secondary outcome measures were: analgesia consumption, visits to the GP or hospital, antibiotic usage, the day on which their swallowing returned to normal and the day on which they returned to work.

RESULTS

111 (58.4%) completed questionnaires were available for analysis. The Arnica group had a significantly larger drop in pain score from day 1 to day 14 (28.3) compared to the placebo group (23.8) with p < 0.05. The two groups did not differ significantly on analgesic consumption or any of the other secondary outcome measures (number of post-operative visits to GP, use of antibiotics and secondary haemorrhage readmissions).

CONCLUSION

The results of this trial suggest that Arnica montana given after tonsillectomy provides a small, but statistically significant, decrease in pain scores compared to placebo.

Unravelling the complexities of the NF-κB signalling pathway using mouse knockout and transgenic models

The nuclear factor-kappaB (NF-kappaB) signalling pathway serves a crucial role in regulating the transcriptional responses of physiological processes that include cell division, cell survival, differentiation, immunity and inflammation. Here we outline studies using mouse models in which the core components of the NF-kappaB pathway, namely the IkappaB kinase subunits (IKKalpha, IKKbeta and NEMO), the IkappaB proteins (IkappaBalpha, IkappaBbeta, IkappaBvarepsilon and Bcl-3) and the five NF-kappaB transcription factors (NF-kappaB1, NF-kappaB2, c-Rel, RelA and RelB), have been genetically manipulated using transgenic and knockout technology.

Pyrexia of unknown origin with neutropenia, cervical lymphadenopathy, pneumonia and marrow hypoplasia

A 56 years adult male presented with fever for 3 weeks with neutropenia and cervical lymphadenopathy with left sided pneumonitis. Histopathology of lymphnode was consistent with Kikuchi's Necrotizing Lymphadenitis. Kikuchi's disease is usually a self- limiting illness characterized by pyrexia, neutropenia and cervical lymphadenopathy in young women of Asian decent. This often leads to the misdiagnosis of lymphoma or tuberculosis. The notable feature here is an older male presented with severe neutropenia and pneumonia with hypoplastic marrow.

Comparison of the dexamethasone-suppressed corticotropin-releasing hormone test and low-dose dexamethasone suppression test in the diagnosis of Cushing's syndrome

CONTEXT

The low-dose dexamethasone suppression test (LDDST) is widely used in confirming a diagnosis of Cushing's syndrome. CRH administration at the end of an LDDST has been reported to improve the diagnostic accuracy of this test.

OBJECTIVE

Our objective was to assess whether CRH administration after a standard LDDST (LDDST-CRH test) improves diagnostic accuracy in Cushing's syndrome.

DESIGN, SETTING, AND PARTICIPANTS

Thirty-six individuals with a clinical suspicion of Cushing's syndrome each completed a standard LDDST and an LDDST-CRH test at Hammersmith Hospitals NHS Trust, London. The LDDST involved administration of 0.5 mg oral dexamethasone given 6-hourly for 48 h. Serum cortisol was measured 6 h after the last dose of dexamethasone, with a value of 50 nmol/liter or below excluding Cushing's syndrome. Immediately after this, the LDDST-CRH test commenced with administration of a ninth dose of 0.5 mg dexamethasone. Exactly 2 h later, 100 mug human-sequence CRH was administered. Serum cortisol was measured 15 min after the CRH injection, with a value of less than 38 nmol/liter also excluding Cushing's syndrome.

MAIN OUTCOME MEASURE

Diagnosis or exclusion of Cushing's syndrome was the main outcome measure.

RESULTS

Twelve subjects were diagnosed with Cushing's syndrome (eight Cushing's disease and four primary adrenal). The sensitivity of the LDDST in diagnosing Cushing's syndrome was 100%, with a specificity of 88%. In contrast, although the sensitivity of the LDDST-CRH test was also 100%, specificity was reduced at 67%. These results give a positive predictive value of 80% for the LDDST and 60% for the LDDST-CRH test.

CONCLUSION

This small study suggests that the addition of CRH to the LDDST does not improve the diagnostic accuracy of the standard LDDST in Cushing's syndrome.

Higher neutrophil infiltration mediated by osteopontin is a likely contributing factor to the increased susceptibility of females to alcoholic liver disease

Alcoholic liver disease (ALD) is a major public health problem in the United States and women are known to be more susceptible to ALD. However, the precise mechanism for increased susceptibility of females to ALD is not completely understood. The present study is based on the hypothesis that induction of osteopontin (OPN), a matricellular protein, is the likely contributing factor for higher neutrophil recruitment in females during alcoholic steatohepatitis (ASH). ASH was induced in male and female Sprague-Dawley rats by feeding them a Lieber-DeCarli diet containing ethanol (EtOH) for 6 weeks, followed by a single injection of lipopolysaccharide (LPS, 10 mg/kg, ip). Liver injury, measured by plasma transaminase elevations and confirmed by haematoxylin and eosin-stained liver sections, revealed approximately 25-fold higher liver injury in the female ASH model compared with the males. Although steatosis, necrosis, and neutrophil infiltration were evident in both male and female rats, hepatic neutrophilic necrotic foci were noted as early as 2 h after LPS injection in the EtOH-treated female rats. Hepatic neutrophil infiltration correlated with higher expression of cleaved (cOPN) and uncleaved OPN in the EtOH + LPS-treated female rats compared with the males. OPN secretion was localized predominantly in the biliary epithelium and females had significantly higher OPN mRNA than their male counterparts in the ASH model. The ability of OPN to attract neutrophils was further confirmed in vivo, in a peritonitis rat model, and by neutralizing OPN (nOPN) antibody experiments. Hepatic neutrophil infiltration was largely inhibited ( approximately 50%) by nOPN antibody. Flow cytometry experiments revealed OPN-mediated up-regulation of the CD11b neutrophil adhesion molecule. In conclusion, these data suggest that higher hepatic expression of OPN is the likely reason for higher and early hepatic neutrophil infiltration making females more susceptible to ALD during ASH.

Length of insertion for pulmonary artery catheters to locate different cardiac chambers in patients undergoing cardiac surgery

BACKGROUND

Although, guidelines related to length of insertion of a pulmonary artery catheter to reach a particular cardiac chamber are available, these are not backed by clinical studies. We measured the length of insertion of pulmonary artery catheters to locate the right ventricle, pulmonary artery and pulmonary capillary wedge positions in 300 adult patients undergoing elective cardiac surgery.

METHODS

The pulmonary artery catheters were inserted using a standard technique through the right internal jugular vein. The right ventricle, pulmonary artery and wedge position of the catheter were confirmed by the characteristic waveforms, and the length of insertion to these points was measured.

RESULTS

The right ventricle was reached at 24.6 (3) cm (95% CI 24.2-24.9 cm), pulmonary artery at 36 (4) cm (95% CI 35.6-36.5 cm) and wedge position at 42.8 (5.7) cm (95% CI 42.2-43.5 cm). The length of catheter to reach the right ventricle, pulmonary artery and wedge position was significantly more in patients undergoing valve surgery as compared with those undergoing coronary artery bypass grafting [26 (3.8) and 24 (2.5) cm; 38.5 (4.6) and 35 (3.2) cm; and 47.8 (6.9) and 41.2 (4.1) cm, respectively, P<0.001]. The length of insertion to reach pulmonary artery and pulmonary capillary wedge position was directly related to height of the patient (Pearson's correlation 0.157 and 0.15, respectively).

CONCLUSIONS

We have provided the norms related to length of insertion of pulmonary artery catheter, which should be useful in accurate placement of the catheter and minimize complications related to coiling of the catheter.

The developing world in The New England Journal of Medicine

BACKGROUND

Rampant disease in poor countries impedes development and contributes to growing North-South disparities; however, leading international medical journals underreport on health research priorities for developing countries.

METHODS

We examined 416 weekly issues of the New England Journal of Medicine (NEJM) over an eight-year period, January 1997 to December 2004. A total of 8857 articles were reviewed by both authors. The content of each issue was evaluated in six categories: research, review articles, editorial, correspondence, book reviews and miscellaneous. If the title or abstract concerned a topic pertinent to any health issue in the developing world, the article was reviewed.

RESULTS

Over the eight years covered in this study, 1997-2004, in the three essential categories of original research articles, review articles and editorials, less than 3.0 percent of these addressed health issues in the developing world. Publications relevant to DC were largely concerned with HIV and communicable diseases and constituted 135 of the 202 articles of which 63 were devoted to HIV. Only 23 articles addressed non-communicable disease in the DC and only a single article - a book review - discussed heart disease.

CONCLUSION

The medical information gap between rich and poor countries as judged by publications in the NEJM appears to be larger than the gap in the funding for research. Under-representation of developing world health issues in the medical literature is a global phenomenon. International medical journals cannot rectify global inequities, but they have an important role in educating their constituencies about the global divide.