'One Is Too Many' preventing self-harm and suicide in military veterans: a quantitative evaluation

INTRODUCTION

In 2021, the Armed Forces Covenant Fund Trust allocated over £2 million to programmes designed to have a clear and demonstrable impact on suicide prevention. Four grant holders delivered a combination of psychotherapeutic interventions, group activities, social prescribing, peer support mentoring, life skills coaching, educational courses and practical help with housing and employment. The evaluation was completed between August 2021 and July 2023.

METHODS

A survey was completed by 503 participants at entry and 423 at exit. It captured data regarding demographic and military-specific details, health status, situational stressors, predisposing symptoms, help-seeking behaviour, social engagement, housing, living arrangements and employment status. The questionnaire included a number of validated psychometric questionnaires.

RESULTS

This evaluation revealed reductions in situational stressors, symptoms and mental health illnesses. Seventy-six per cent of participants had completed an Operational Tour, and 77% were exposed to a traumatic event during service. It was the negative impact of unresolved traumatic effects that influenced service-users to require support. Forty-nine per cent delayed seeking help, and 36% self-referred to the One Is Too Many programme which demonstrates the importance of this option. There were improvements in the participants' social networking, social activities, club membership and having people to rely on. Only 4% of participants were women which reinforces the requirement to explore initiatives to engage with female veterans.

CONCLUSIONS

Timely therapeutic and social prescribing interventions in a safe environment lowered depression, anxiety and the associated situational stressors leading to self-harming and may have reduced suicide. It presented another option to veterans and their families regarding where they can obtain support, care and therapeutic interventions. The programme provided a strong foundation for delivery organisations to forge lasting collaborative partnerships that can be extended to working with other authorities and institutes. The results highlight pathways for prevention and intervention strategies to inform policymakers, healthcare professionals and third-sector organisations.

Trends in Utilization of Completion Imaging after Lower Extremity Bypass and Its Association with Major Adverse Limb Events and Loss of Primary Patency

BACKGROUND

Failure following lower extremity bypasses (LEBs) isoften secondary to technical defects. Despite traditional teachings, routine use of completion imaging (CI) in LEB has been debated. This study assesses national trends of CI following LEBs and the association of routine CI with 1-year major adverse limb events (MALE) and 1-year loss of primary patency (LPP).

METHODS

The Vascular Quality Initiative (VQI) LEB dataset from 2003-2020 was queried for patients who underwent elective bypass for occlusive disease. The cohort was divided based on surgeons' CI strategy at time of LEB, categorized as routine (≥80% of cases/year), selective (<80% of cases/year), or never. The cohort was further stratified by surgeon volume category [low (<25th percentile), medium (25th-75th percentile), or high (>75th percentile)]. The primary outcomes were 1-year MALE-free survival and 1-year loss of primary patency (LPP)-free survival. Our secondary outcomes were temporal trends in CI use and temporal trends in 1-year MALE rates. Standard statistical methods were utilized.

RESULTS

We identified 37,919 LEBs; 7,143 in routine CI strategy cohort, 22,157 selective CI and 8,619 in never CI. Patients in the 3 cohorts had comparable baseline demographics and indications for bypass. There was a significant decrease in CI utilization from 77.2% in 2003 to 32.0% in 2020 (P < 0.001). Similar trends in CI use were observed in patients who underwent bypass to tibial outflows (86.0% in 2003 vs. 36.9% in 2020; P < 0.001). While the use of CI has decreased over time, 1-year MALE rates have increased from 44.4% in 2003 to 50.4% in 2020 (P < 0.001). On multivariate COX regression, however, no significant associations between CI use or CI strategy and risk of 1-year MALE or LPP was found. Procedures performed by high-volume surgeons carried a lower risk of 1-year MALE (HR: 0.84; 95% CI [0.75-0.95]; P = 0.006) and LPP (HR:0.83; 95% CI [0.71-0.97]; P < 0.001) compared to low-volume surgeons. Repeat adjusted analyses showed no association between CI (use or strategy) and our primary outcomes when the subgroups with tibial outflows were analyzed. Similarly, no associations were found between CI (use or strategy) and our primary outcomes when the subgroups based on surgeons' CI volume were evaluated.

CONCLUSIONS

The use of CI, for both proximal and distal target bypasses, has decreased over time while 1-year MALE rates have increased. Adjusted analyses indicate no association between CI use and improved MALE or LPP survival at 1 year and all CI strategies were found to have equivalent outcomes.

Stenting performs better than drug-coated balloon angioplasty in popliteal lesions

BACKGROUND

Peripheral arterial disease (PAD) is a common and highly morbid disease. Although there have been recent advancements in the endovascular modalities to treat PAD, comparisons of these strategies, especially in the popliteal region, remain underinvestigated. The objective of this study was to compare midterm outcomes in patients with PAD undergoing treatment with both novel and SS compared with drug-coated balloon (DCB) angioplasty.

METHODS

All patients at a multi-institution health system treated for PAD in the popliteal region from 2011 to 2019 were identified. Presenting features, operative details, and outcomes were included in the analysis. Patients who underwent popliteal revascularization with stents were compared with DCB. SS were compared separately with novel dedicated stents. Two-year primary patency was the primary outcome.

RESULTS

We included 408 patients (72.7 ± 11.8 years old; 57.1% men) in the analysis. There were 221 (54.7%) patients who underwent popliteal stenting and 187 (45.3%) who underwent popliteal DCB. There were high rates of tissue loss in both groups (57.9% vs 50.8%; P = .14). Stented patients had longer lesions (112.4 ± 3.2 vs 100.2 ± 5.8 mm; P = .03) and higher rates of concomitant superficial femoral artery treatment (88.2% vs 39.6%; P < .01). Chronic total occlusions accounted for the majority of lesions treated (stent 62.4%, DCB 64.2%). Perioperative complications were similar between groups. Primary patency for the stented group was higher at two years than the DCB group (61.0% vs 46.1%; P = .03). When evaluating stented patients only, SS had higher 2-year patency than novel stents in the popliteal segment (69.6% vs 51.4%; P = .04). On multivariable analysis, stenosis, as opposed to chronic total occlusion, was associated with improved patency (hazard ratio, 0.49; 95% confidence interval, 0.25-0.96; P = .04), whereas novel stents were associated with worse primary patency (hazard ratio, 2.01; 95% confidence interval, 1.09-3.73; P = .03).

CONCLUSIONS

In a population of patients with severe vascular disease, stents do not have inferior patency and limb salvage rates compared with DCB angioplasty when treating the popliteal region. For patients with advanced vascular disease, and especially tissue loss, stents and DCB are both beneficial when treating popliteal lesions.

Evaluation of the NHS England 'Op COURAGE' High Intensity Service for military veterans with significant mental health problems

INTRODUCTION

In November 2020, The NHS for England launched a pilot High Intensity Service (HIS) programme for treating military veterans complex mental health problems. Seven regional grants were awarded to manage the HIS, including NHS Solent, in South East England. This paper details an evaluation of the HIS, which was conducted from February 2021 to August 2022.

METHODS

This mixed-methods study gained quantitative data from a specifically designed questionnaire that included a number of validated psychometric questionnaires. These were completed by either HIS staff or beneficiaries at entry and exit from the HIS, and qualitative data were gained from semi-structured interviews with the HIS staff.

RESULTS

Data were sourced from 45 pre-questionnaires, 25 post programme questionnaires and 11 interviews. This evaluation identified reductions in situational stressors, symptoms and reported illnesses for veterans in crisis. There were reductions in depression, anxiety and post-traumatic stress disorder following programme exit. Staff reported that there was no notable changes in stress levels which appeared to remain high at programme exit. Staff interviews highlighted the importance of simultaneously understanding the social and psychological needs of veterans in mental health crisis. The benefits of integrating veteran staff members into military veteran health services were identified, demonstrating improvements in education around military culture in civilian services.

CONCLUSIONS

The importance of collaboration between clinical and veteran staff members in veteran health services was noted, demonstrating the positive impact social care provision has on veteran's overall health and well-being. Veteran engagement with the service was advocated as a result of veterans accessing the service feeling understood. This first independent evaluation of the HIS provides a positive reflection, and adds to the limited empirical evidence exploring veteran engagement in health services.

Acute Deep Vein Thrombosis Involving the Inferior Vena Cava: Interventional Perspectives

Extension of an iliofemoral thrombosis into the inferior vena cava (IVC), or from the IVC descending into the iliofemoral segments, can confer significant morbidity and mortality. Interventional management of acute deep vein thrombosis (DVT) has been controversial, but there is little doubt that certain subpopulations benefit, such as those with symptomatic IVC thrombosis. When considering an intervention, caval involvement introduces technical difficulties due to its larger diameter, high thrombus burden, bilateral limb clot extension and need for dual access. The frequent coexistence of an IVC filter increases the complexity even more. This review summarises the current indications and treatment modalities available for the management of acute DVT involving the vena cava.

Malpractice litigation and spinal surgery in the National Health Service: a single tertiary-level centre perspective over 12 years

INTRODUCTION

Medical malpractice litigation is a major concern for all spine surgeons. Our aim was to evaluate the incidence and burden of successful litigation relating to the management of spinal disorders over 12 years within a UK NHS tertiary-level spinal unit and compare these litigation costs with those of other specialties.

METHODS

We obtained all data held by our claims department from its inception in January 2008 to December 2019. We also obtained costs for the total financial burden incurred by our Trust during this period.

RESULTS

In total, there were 83 closed claims involving spinal pathologies. Over 80% of these comprised negligent surgery (n = 28, 34%), delay to diagnose/treat (n = 25, 30%) and negligent care (n = 18, 22%). The vast majority of claims were withdrawn without incurring any cost to the hospital (n = 59, 71%) and only 24 (29%) resulted in successful litigation for the claimant. The total cost of damages for these 24 successful claims was just over £8 million, including legal costs of £2.5 million, out of total litigation costs of £381 million over this period.

DISCUSSION

Fewer than 30% of initial claims against a tertiary spinal surgical referral unit resulted in a successful financial outcome for the claimant. The total costs incurred were just over £8 million, with one-third apportioned to high legal costs, reflecting the complexity of resolving spinal litigation. Our entire legal expenses accounted for only 2% of the total legal bill paid by our hospital over a 12-year period.

Dynamic Luminal Topography: A Potential Strategy to Prevent Vascular Graft Thrombosis

Aim

Biologic interfaces play important roles in tissue function. The vascular lumen-blood interface represents a surface where dynamic interactions between the endothelium and circulating blood cells are critical in preventing thrombosis. The arterial lumen possesses a uniform wrinkled surface determined by the underlying internal elastic lamina. The function of this structure is not known, but computational analyses of artificial surfaces with dynamic topography, oscillating between smooth and wrinkled configurations, support the ability of this surface structure to shed adherent material (Genzer and Groenewold, 2006; Bixler and Bhushan, 2012; Li et al., 2014). We hypothesized that incorporating a luminal surface capable of cyclical wrinkling/flattening during the cardiac cycle into vascular graft technology may represent a novel mechanism of resisting platelet adhesion and thrombosis.

Methods and Results

Bilayer silicone grafts possessing luminal corrugations that cyclically wrinkle and flatten during pulsatile flow were fabricated based on material strain mismatch. When placed into a pulsatile flow circuit with activated platelets, these grafts exhibited significantly reduced platelet deposition compared to grafts with smooth luminal surfaces. Constrained wrinkled grafts with static topography during pulsatile flow were more susceptible to platelet accumulation than dynamic wrinkled grafts and behaved similar to the smooth grafts under pulsatile flow. Wrinkled grafts under continuous flow conditions also exhibited marked increases in platelet accumulation.

Conclusion

These findings provide evidence that grafts with dynamic luminal topography resist platelet accumulation and support the application of this structure in vascular graft technology to improve the performance of prosthetic grafts. They also suggest that this corrugated structure in arteries may represent an inherent, self-cleaning mechanism in the vasculature.

Complete Venous Ulceration Healing after Perforator Ablation Does Not Depend on Treatment Modality

BACKGROUND

Venous leg ulceration (VLU) represents the most advanced form of chronic venous insufficiency (CVI). Persistent VLU that fails to respond to noninvasive treatment requires a minimally invasive endovascular treatment, which may include chemical (ultrasound-guided foam sclerotherapy [UGFS]) and thermal ablation (endovenous laser therapy [EVLT] or radiofrequency ablation [RFA]) targeting incompetent veins. Current guidelines suggest ablation of incompetent perforating veins (IPVs) juxtaposed to active or healed VLU; however, the ideal treatment modality is unknown. We hypothesize that similar to incompetent superficial vein treatment options therapies, VLU healing will be equivalent across minimally invasive IPV treatment options.

METHODS

Using the Vascular Low Frequency Disease Consortium, adults with VLU across 11 medical centers were retrospectively reviewed (2013-2017). We included those who underwent IPV therapies. The primary outcome was complete ulcer healing over time compared with cumulative hazard curves, log-rank testing, and multivariable Cox proportional hazard regression. Secondary outcomes included number of subsequent procedures, which were compared using negative binomial regression.

RESULTS

Of the 832 adults with VLU, 158 (19%) were exclusively treated conservatively, and 232 (28%) underwent index treatment for IPV and constitute the full and final cohort. The mean age was 60 ± 14 years, 57% were men, and the mean ulcer area was 3.0 cm² (interquartile range, 1-6 cm²). Ninety-one (39%) were treated with EVLT, 127 (55%) RFA, and 14 (6%) UGFS. Patients treated with RFA were older (RFA 62 ± 14 years; EVLT 59 ± 14 years; UGFS 52 ± 9 years; P = 0.01), more likely to be men (RFA 68%, n = 86; EVLT 41%, n = 37; UGFS 64%, n = 9; P < 0.001), with a higher frequency of anticoagulation (RFA 36%, n = 46; EVLT 18%, n = 16; UGFS 14%, n = 2; P = 0.005). VLU did not significantly differ in size between groups (RFA 6.2 ± 8; EVLT 4.2 ± 5.4; UGFS 6.1 ± 8; P < 0.001). There were no differences in 1-year ulcer healing rates between groups (P = 0.18). The number of subsequent procedures did not differ by treatment modality (P = 0.47).

CONCLUSIONS

This multi-institutional retrospective study does not demonstrate any association of IPV treatment modality with differing rates of VLU healing or number of subsequent procedures.

Systemic vasoprotection by inhaled carbon monoxide is mediated through prolonged alterations in monocyte/macrophage function

Carbon monoxide (CO) is anti-inflammatory and protective in models of disease. Its actions in vitro are short-lived but are sustained in vivo. We hypothesize that systemic CO can mediate prolonged phenotype changes in vivo, with a focus on macrophages (Mφs). Mφs isolated from CO treated rats responded to lipopolysaccharide (LPS) with increased IL6, IL10 and iNOS expression but decreased TNF. Conditioned media (CM) collected from peritoneal Mφs isolated from CO treated rats stimulated endothelial cell (EC) proliferation versus CM from Mφs from air treated rats. This effect was mediated by Mφ released VEGF and HMGB1. Inhaled CO reduced LPS induced Mφ M1 inflammatory phenotype for up to 5 days. Mitochondrial oxygen consumption in LPS treated Mφs from CO treated mice was preserved compared to LPS treated Mφs from control mice. Finally, transient reduction of inflammatory cells at the time of inhaled CO treatment eliminated the vasoprotective effect of CO in a rodent carotid injury model. Thus, inhaled CO induces a prolonged mixed phenotype change in Mφs, and potentially other inflammatory cells, that contribute to vasoprotection. These findings demonstrate the ability of inhaled CO to modify Mφs in a sustained manner to mediate its therapeutic actions, supporting the translational potential of inhaled CO.

Abstract 537: Nature’s Surfaces: a Potential Role for Arterial Wrinkles in Vascular Homeostasis

Biologic interfaces play important roles in tissue function. The tissue-blood interface in blood vessels represents a dynamic interaction between the endothelium and circulating RBCs, platelets and inflammatory cells. This interface is critical in regulating vascular thrombosis. While the study of vascular homeostasis has focused on the endothelium, the arterial lumen has been shown to possess a regular wrinkled pattern that has been previously attributed to fixation artifact. We hypothesize that the arterial luminal surface undergoes phasic wrinkling and flattening driven by the cardiac cycle and this dynamic topography may represent a novel mechanism of resisting platelet adhesion. Using an ex vivo pulsatile pump system to actuate arteries and grafts, we examined the effect of physiologic pressures on luminal topography and the effect of dynamic topography on platelet adhesion in vascular graft function. Pig carotid arteries were distended to 40-140 mmHg, fixed, and examined histologically for luminal surface wrinkle amplitudes. Arteries at 40 mmHg had an average wrinkle amplitude of 20.52 ± 4.13 μm which decreased to 5.86 ± 1.69 μm at 140 mmHg ( p <0.05; Figure 1A-D). We synthesized silicone grafts with a wrinkled luminal surface similar to the arteries or with a smooth surface. The grafts were placed on a pulsatile pump circuit set to a systolic pressure of 100-120 mmHg and activated platelets were circulated through the graft. Wrinkled grafts undergoing pulsatile flow exhibited an 87% reduction in platelet deposition by Giemsa stain in comparison to grafts with smooth luminal surfaces ( p <0.05, Figure1E,F). These findings confirm that arteries do possess luminal topography that varies with physiologic ranges in blood pressure. Grafts that mimic this behavior show reduced platelet accumulation, suggesting that dynamic topography contributes to vascular homeostasis. Incorporation of this topography into vascular grafts may improve graft patency.

Dental health and oral health-related quality of life in children with congenital bleeding disorders

The purpose of this study was to investigate the dental and some other aspects of oral health status of young patients with congenital bleeding disorders (CBD) and the impact of these on their quality of life (OHR-QoL) compared with controls. DMFS-dmfs (Decayed, Missed, Filled Tooth surfaces in permanent and primary teeth) scores, Simplified oral hygiene index, occurance of hypoplasia of first permanent molars, Temporomandibular joint dysfunction and occlusion of 46 CBD patients at the age range of 2-15 years and 46 of other children as control were compared, and the impact of their oral health situation on quality of life was also investigated. Data were analysed by chi-square, t-test and Pearson correlation. Patients were significantly more caries-free with less decayed teeth in primary-permanent dentition (P = 0.03, t = -2.17).The mean scores of OHR-QoL of CBD patients and controls were not significantly different. Oral Bleeding was the significant variable in relation to 'oral health-related quality of life' in CBD groups (Pearson correlation, r = -0.56, P = 0.000). OHR-QoL in the control group was related to dmfs score (r = -0.392, P = 0.011) and male gender (r = -0.329, P = 0.026). Congenital bleeding disorder CBD patients were found to have a better dental health situation in primary dentition compared with controls; however, their 'oral health-related quality of life' was similar. Oral bleeding was the only significant factor related to OHR-QoL in CBD. It shows an overall importance of development of comprehensive care centres for CBD as the main cause of this achievement.

Ischaemic posterior circulation stroke in State of Qatar

BACKGROUND

Ischaemic stroke features may show regional differences. Posterior circulation stroke (PCS) is of special interest, as symptomatology, course and outcome are usually different and complex. No significant studies or registries have reported on the characteristics and outcomes of PCS in our region.

METHODS

We prospectively collected data of 116 patients with PCS admitted from 2005 through 2008 in the only stroke admitting hospital in Qatar. Demographics, risk factors, clinical signs/symptoms, pattern of presentation, aetiology, imaging features, complications and outcome at discharge and follow-up were recorded.

RESULTS

Mean age was 53 years with 25% aged < or = 45, 85% were males. Demographically 47% were Arabs and 51% of South-Asian origin. Mean duration from onset to presentation was 29 h. Major risk factors were obesity (66%) and hypertension (61%). Minimal or fluctuating symptoms were present in 64%, while 9% had maximal deficit at onset. Thirty nine per cent had lesions in proximal territory and 23% in multiple territories. Around 41% had no occlusion, 16% had vertebro-basilar, 16% vertebral, 8% basilar occlusion. Etiologically 53% patients had large artery disease, 16% small vessel disease, and 17% cardioembolism. Seventy per cent of patients were discharged home, while 10% expired. Modified Rankin score (mRS) at discharge was < or = 2 in 53% and > or = 4 in 13% patients. At 30-day follow-up, 68% had mRS of < or = 2. Ninety-day survival status showed 89% alive with mRS < or = 2 in 73%.

CONCLUSION

The aetiology and lesion topography of PCS in this heterogeneous population differs from the pattern observed in other populations.

Complex tibial plateau fractures treated with Ilizarov external fixator with or without minimal internal fixation

We treated 30 tibial plateau fractures (Schatzker Type VI) in 29 patients, with a mean age of 41.4 (20-76) years, with the Ilizarov fixator. In 18 fractures, we combined the treatment with minimal internal fixation. All fractures were the result of high-energy trauma, and 20 patients had associated injuries. Twenty-eight fractures were available for follow-up after 27 (16-36) months. Using The Knee Society clinical rating system, 18 knees were rated as excellent, seven as good, one as fair, and two as poor. There was a direct correlation between the presence of associated injuries and the final outcome. The most significant concomitant injuries were distal femoral fractures and extensive soft-tissue injury. This study emphasizes the clinical success and low morbidity associated with the use of external fixation and minimal internal fixation.

Sensitive kinetic spectrophotometric determination of captopril and ethamsylate in pharmaceutical preparations and biological fluids

A highly sensitive kinetic spectrophotometric method was developed for the determination of captopril (CPL) and ethamsylate (ESL) in pharmaceutical preparations and biological fluids. The method is based on a catalytic acceleration of the reaction between sodium azide and iodine in an aqueous solution. Concentration range of 0.1-1.5 microg ml(-1) for CPL and 0.3-3 microg ml(-1) for ESL was determined by measuring the decrease in the absorbance of iodine at 348 nm by a fixed time method. The decrease in absorbance after 5 min was markedly correlated to the concentration. The relative standard deviations obtained were 1.30 and 1.87 for CPL and ESL, respectively, in pure forms. Correlation coefficients were 0.9997 and 0.9999 for CPL and ESL, respectively. The detection limits were determined as (S/N = 3) were 20 ng ml(-1) for CPL and 50 ng ml(-1) for ESL. The proposed procedure was successively applied for the determination of both drugs in pharmaceutical preparations and in biological fluids.

3 Tesla-MRT: Der Erfolg h�herer Feldst�rken

The recent development of 3 Tesla MRI (3T MRI) has been fueled by promise of increased signal-to-noise ratio(SNR). Many are excited about the opportunity to not only use the increased SNR for clearer images, but also the chance to exchange it for better resolution or faster scans. These possibilities have caused a rapid increase in the market for 3T MRI, where the faster scanning tips an already advantageous economic outlook in favor of the user. As a result, the global market for 3T has grown from a research only market just a few years ago to an ever-increasing clinically oriented customer base. There are, however, significant obstacles to 3T MRI presented by the physics at higher field strengths. For example, the T1 relaxation times are prolonged with increasing magnet field strength. Further, the increased RF-energy deposition (SAR), the larger the chemical shift and the stronger susceptibility effect have to be considered as challenges. It is critical that one looks at both the advantages and disadvantages of using 3T. While there are many issues to address aand a number of different methods for doing so, to properly tackle each of these concerns will take time and effort on the part od researchers and clinicians. The optimization of 3T MRI scanning will have to be a combined effort, though much of the work to date has been in neuroimaging. Multiple applications have been explored in addition to clinical anatomical imaging, where resolution is improved showing structure in the brain never seen before in human MRI. Body and cardiac imaging provide a great challenge but are also achievable at 3T. As an example, the full range of clinical applications currently achieved on today's state-of-the-art 1.5T cardiac MR scanners has also been demonstrated at 3T. In the body, the full range of contrast is available over large fields of view allowing whole liver studies in the clinic or, as needed, one may choose a smaller field of view for high-resolution imaging of the pancreas. The ability to increase resolution for musculoskeletal imaging has provided previously unseen detail. Bone structure, cartilage, and tendons and ligaments can be clearly visualized and pathology more easily detected due to an increased image quality. As the increase in field strength continues, a push to look at 7T has begun. The design philosophy is to keep the system as similar as possible, while changing only the frequency-dependent components. To date, both animal and human imaging have been performed on a whole body 7T scanner. Results show promise for both detailed imaging and functional MRI, but the road ahead is too long to be able to predict where it will end. The move toward higher field strengths is an exciting adventure in which 3T plays the role of trailblazer.

Infections in children under 5 years old and latrine cleanliness

The aim of this study is to assess the cleanliness of the latrine and its relation to occurrence of disease in children under 5 years old. A stratified random sample of 1327 households was conducted in 11 villages in Upper Egypt. It included a sub-sample of 541 children under 5 years living in households with latrines. The latrine cleanliness was assessed and its relationship to disease occurrence within a period of 2 weeks. Thirty-three percent (33.1%) of children under 5 years old with latrines in their household had infections, compared to 28.3% of those without latrines in the house. Infection with diarrhoea was found most in houses with latrine and water tap. A relation was found between latrine cleanliness score and presence of flies, house building material and maternal education, but none with occurrence of infection in children under 5 years old within a period of 2 weeks.

Echocardiographically guided pericardiocentesis - the gold standard for the management of pericardial effusion and cardiac tamponade

BACKGROUND

The conventional surgical pericardiotomy and blind needle-puncture pericardiocentesis using a subxiphoid approach have been reported to have only moderate success rates and to be associated with unacceptably high rates of morbidity and mortality. More recently, echocardiographically guided pericardiocentesis was reported to improve considerably the likelihood of success and the safety of this procedure.

OBJECTIVE

To evaluate the efficacy and safety of echocardiographically guided pericardiocentesis in the authors' institution.

PATIENTS AND METHODS

A series of consecutive patients who underwent percutaneous pericardiocentesis at the Hamilton General Hospital, Hamilton, Ontario, from June 1994 to December 1998.

RESULTS

Forty-one patients underwent a total of 46 echocardiographically guided pericardiocentesis procedures. The procedure was successful in 100% of attempts. Clinical complications occurred in two (5%) patients: one patient with known coagulopathy developed hemothorax and one patient developed purulent pericarditis several days after the procedure. There were no deaths, and no patient required urgent referral for surgical management.

CONCLUSIONS

Echocardiographically guided pericardiocentesis is safe and effective, and is the method of choice for therapeutic and diagnostic drainage of pericardial effusions. While echocardiographically guided pericardiocentesis was described originally at centres with large volumes of patients with clinically significant pericardial effusions and with extensive experience in using this technique, similar high success and low complication rates were attained at an institution with relatively low numbers of patients requiring pericardial drainage.

Antimicrobial activity of 20 plants used in folkloric medicine in the Palestinian area

Ethanolic and aqueous extracts of 20 Palestinian plant species used in folk medicine were investigated for their antimicrobial activities against five bacterial species (Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae, Proteus vulgaris, Pseudomonas aeruginosa) and one yeast (Candida albicans). The plants showed 90% of antimicrobial activity, with significant difference in activity between the different plants. The most antimicrobially active plants were Phagnalon rupestre and Micromeria nervosa, whereas, the least active plant was Ziziphus spina-christi. Only ten of the tested plant extracts were active against C. albicans, with the most active from M. nervosa and Inula viscosa and the least active from Ruscus aculeatus. Of all extracts the ethanolic extract of M. nervosa was the most active, whereas, the aqueous extract of Phagnalon rupestre was the most active of all aqueous extracts tested. The ethanolic extracts (70%) showed activity against both Gram positive and negative bacteria and 40% of these extracts showed anticandidal activity, whereas, 50% of the aqueous extracts showed antibacterial activity and 20% of these extracts showed anticandidal activity.