Comparative study of peripheral blood smear, quantitative buffy coat and modified centrifuged blood smear in malaria diagnosis

The present study was aimed at modifying the centrifuged blood smear (modified centrifuged blood smear or MCBS), to make it a feasible and standardized procedure. The results obtained were compared with the current diagnostic methods - peripheral blood smear (PBS) and quantitative buffy coat (QBC). Blood samples collected from 100 suspected malaria patients were subjected to all three tests. It was found that PBS had 86.79% sensitivity and was absolutely specific. QBC was 96.22% sensitive and 93.61% specific. The majority of variations occurred in PBS negative cases; cases with parasite count Plasmodium falciparum. It was seen that by the addition of centrifugation to the conventional smear technique (MCBS) improved its sensitivity from 86.79% to near 100%. QBC and MCBS were found superior to PBS. Since MCBS combines principles of both QBC and PBS, it is as sensitive as QBC, as specific as PBS, and above all, easily performed and affordable.

Cosmetic and radiological outcome following the use of synthetic hydroxyapatite porous-dense bilayer burr-hole buttons

BACKGROUND

Cranial neurosurgical procedures utilising burr-holes lead to development of cosmetically unacceptable puckered scars on the scalp over burr-hole sites. Ceramics, especially Hydroxyapatite (HA) are good bone substitutes owing to their biocompatibility and osteoconduction i.e. ability to lay down bone over the implant by fibrovascular invasion and later bone formation. The Sree Chitra Tirunal Institute for Medical Sciences and Technology in India has pioneered research in this direction and has developed a unique porous-dense bilayer HA burr-hole button. This study evaluates the safety, cosmetic effect, as well as the radiological outcome following implantation of these bilayer HA buttons.

METHOD

Sixty-five HA buttons were implanted in 22 patients who underwent cranial neurosurgical procedures at the Sree Chitra Tirunal Institute for Medical Sciences and Technology. We assessed the cosmetic outcome (absence of puckered scar over burr hole sites, absence of allergic reactions or infections associated with the implant) as well as the radiological outcome with X-rays at specified intervals and looked for interference in the postoperative neurological imaging due to the implants.

RESULTS

There were no adverse events related to the HA buttons in the form of allergic reactions or infections. The implants persisted as radio-dense opacities on skull X-rays of recipients for up to two years. It did not lead to artefacts on postoperative CT or MR imaging of the brain. In particular, the HA buttons could be subtracted on Digital Subtraction Angiography and did not obstruct visualisation of the cerebral vasculature.

CONCLUSION

The bi-layer porous-dense HA buttons are useful in preventing cosmetic defects over burr-hole sites on the scalp after cranial neurosurgical procedures. It does not interfere with current radiological imaging methods in the postoperative phase.

Clinical manifestations of lead workers of Mangalore, India

Objective: To correlate blood lead levels and clinical manifestations. Participants: Battery workers and painters (occupationally exposed to lead in and around Mangalore, India) and occupationally unexposed controls. Main outcome measures: We measured the blood lead levels by anodic stripping voltammetry, and a clinical examination was carried out on all participants. Results: There was a statistically significant difference between the lead-exposed group and controls with respect to clinical manifestations. The prominent findings among the lead-exposed group were fatigue, abdominal colic, abdominal discomfort, backache, muscular exhaustability, myalgia and paresthesia, at a blood lead level ranging from 0.4 to 116.6 μg/dL. Conclusions: Such a study on battery workers and painters has not been reported in India. Several attempts have been made over the years to relate blood lead levels to adverse health effects. It was not possible to determine a precise blood lead level below which symptoms never occur or a blood lead level at which symptoms are always reported. Toxicology and Industrial Health 2006; 22: 405-413.

Characterization of surface modified polyester fabric

Woven polyethylene terephthalate (PET) fabric has been used in the construction of vascular grafts and sewing ring of prosthetic heart valves. In an effort to improve haemocompatibility and tissue response to PET fabric, a fluoropolymer, polyvinylidine fluoride (PVDF), was coated on PET fabric by dip coating technique. The coating was found to be uniform and no significant changes occurred on physical properties such as water permeability and burst strength. Cell culture cytotoxicity studies showed that coated PET was non-cytotoxic to L929 fibroblast cell lines. In vitro studies revealed that coating improved haemocompatibility of PET fabric material. Coating reduced platelet consumption of PET fabric by 50%. Upon surface modification leukocyte consumption of PET was reduced by 24%. About 60% reduction in partial thromboplastin time (PTT) observed when PET was coated with PVDF. Results of endothelial cell proliferation studies showed that surface coating did not have any substantial impact on cell proliferation. Overall results indicate that coating has potential to improve haemocompatibility of PET fabric without affecting its mechanical performance.

Topiramate for anger control: A systematic review

BACKGROUND

Uncontrolled anger while being most commonly associated with personality disorders could also be part of many other conditions such as chronic low back ache and post-traumatic stress disorder. The intensity of anger as an emotional state at a particular time is known as "State Anger," whereas how often angry feelings are experienced over time is known as "Trait Anger." Anger could also manifest as expression of anger toward other persons or objects in the environment (Anger-Out), holding in or suppressing angry feelings (Anger-In) and controlling angry feelings by preventing the expression of anger toward other persons or objects in the environment or controlling suppressed angry feelings by calming down or cooling off (Anger Control).

OBJECTIVE

To prove the effectiveness of topiramate in the control of anger as compared to placebo and to disprove that its use leads to psychiatric adverse events by systematically reviewing the available randomized controlled trials.

MATERIALS AND METHODS

The basic search was performed in MEDLINE (1966 through November 2008) combined with the optimal search strategy for randomized controlled trials described in the Cochrane Reviewers' Handbook. To update this search, we regularly screened citations from PubMed till November 2008 for eligible studies or reviews that might include eligible studies. The Cochrane Central Register of Controlled Trials (CENTRAL) was searched using the terms "topiramate" and "anger or aggression." In addition, we screened bibliographies of reviews and identified articles. Randomized clinical trials wherein study participants were aggressive adults were included.

RESULTS

We could arrive at a weighted mean difference of -3.16 (-3.64 to -2.68) in State Anger. The reduction in the score was highest in borderline personality disorder (BPD) patients as compared to those with low back ache. Trait Anger dropped by -2.93 (-3.49 to -2.37), especially in female BPD patients. Anger In reduced more or less uniformly across the studies by -1.43 (-1.84 to -1.03). Anger Out decreased by -2.8 (-3.19 to -2.42). This effect was minimal among the male BPD patients. Anger Control uniformly increased across the four studies by 2.32 (2.00-2.64). There is sufficient evidence to suggest that topiramate is significantly effective in stabilizing the "trait anger" while reducing the "state anger." "Anger Out" and "hostility" were significantly reduced. "Anger In" was the feature that was the least affected, although this was significant. This suggests that topiramate is effective in controlling anger. There was no suggestion of topiramate precipitating psychomorbidity.

CONCLUSIONS

Topiramate appears to be a safe and effective drug in the management of anger/aggression. Additional research is needed to determine whether these results can be reproduced and how long lasting are the benefits of long-term treatment with topiramate.

Scaling up of facility-based neonatal care: a district health system experience

With proportion of neonatal mortality increasing within under-five deaths, innovative approaches and stronger health systems are needed in neonatal care. We present data of a scaled-up neonatal facility in a District Government Headquarters hospital in Southern India. The special care neonatal unit (SCNU) was a community propelled, public private partnership worked out on the principles of private funding of public institutions and effective budgeting of the public health care system. In the first phase the unit was optimized over 3 years with non-governmental organizations (NGO) and government support from a basic nursery to a SCNU. The unit was operational through fixed maintenance budget from government and mobilized funds from NGOs and beneficiaries. Community health workers were motivated for effective utilization. In the second phase the unit's performance was studied and statistically analyzed in two time frames before and 5 years into the upgradation process. Neonatal admissions from the district increased by 14.65%. Hospital stillbirth, early neonatal and perinatal mortality rates showed significant decline (p < 0.05). There was a 48.59% (CI: 25.46-77.80) increase in antenatal referrals from community health centers. Caesarian sections for neonatal parameters that affect obstetric decisions showed percent changes of 163.25 (CI: 31.18-430.45) and 73.4 (CI: 14.15-164.39) for prematurity and low birth weight (LBW), respectively. Significant decline in case fatality rates for LBW, sepsis and birth asphyxia (p < 0.001) were observed. The district perinatal mortality rate showed a decline. Within the purview of financial constraints of the public health system, private funding, public-private cooperation and effective budgeting may become significant. Motivation of health workers and community to effectively utilize public health care services sets an evolutionary process of referral and vertical linkage of health care system.

Comparison of training in neonatal resuscitation using self inflating bag and T-piece resuscitator

BACKGROUND

Both the self inflating bag and the T-piece resuscitator are recommended for neonatal resuscitation, but many health care workers are unfamiliar with using the latter. A prospective, comparative, observational study was done to determine the ease and effectiveness of training of health care personnel in the two devices using infant training manikins.

METHODS

100 health care workers, who had no prior formal training in neonatal resuscitation, were divided into small groups and trained in the use of the two devices by qualified trainers. Assessment of cognitive skills was done by pre and post MCQs. Psychomotor skill was assessed post training on manikins using a 10-point objective score. Acceptance by users was ascertained by questionnaire. Assessments were also done after 24 h and 3 months. Comparison was done by Chi square and paired t-tests.

RESULTS

Pre-training cognitive tests increased from 3.77 (+1.58) to 6.99 (+1.28) on day of training which was significant. Post training assessment of psychomotor skills showed significantly higher initial scores for the T-piece group (7.07 + 2.57) on day of training. Reassessment after 24 h showed significant improvement in cognitive scores (9.89 + 1.24) and psychomotor scores in both groups (8.86 + 1.42 for self inflating bag and 9.70 + 0.57 for T-piece resuscitator). After 3-6 months the scores in both domains showed some decline which was not statistically significant. User acceptability was the same for both devices.

CONCLUSION

It is equally easy to train health care workers in both devices. Both groups showed good short term recall and both devices were equally acceptable to the users.

Safety and effectiveness of bubble continuous positive airway pressure in preterm neonates with respiratory distress

BACKGROUND

Studies on Bubble Continuous Positive Airway Pressure (B-CPAP) as respiratory support for neonates are few. The aim of our study was to determine the efficacy and safety of B-CPAP in preterm neonates requiring respiratory support.

METHODS

A prospective observation study was done on 50 preterm babies requiring respiratory support for mild to moderate respiratory distress. Support was given with short, nasal cannulae. Surfactant was administered when indicated. Monitoring was done clinically, with pulse oximeter, radiologically and with blood gases. Staff members were also asked their views. Follow-up was done for 3 months.

RESULTS

The mean gestational age was 32.46 (+3.23) weeks and mean birth weight 1454.4 (+487.42) g. Respiratory Distress Syndrome was the commonest indication (30/50). The mean maximum pressure was 6.04 cm H2O and mean maximum FiO2 was 72.16%. Mean maximum paO2, paCO2 and mean minimum paCO2 were 92.93 mm Hg (+16.97), 52.36 mm Hg (+ 7.78) and 36.46 mm Hg (+ 4.95) respectively. Early initiation resulted in lesser duration of support. Failure rate was 30%. Apnoea, >1 dose surfactant and late initiation had a statistically higher incidence of failure. Main complications were skin abrasions (30%), feed intolerance (26%) and gastric distension (26%). Survival rate was 94%. 68% of staff felt that it was as easy to use and 88% felt it was more reliable than standard CPAP.

CONCLUSIONS

Bubble Continuous Positive Airway Pressure is safe, efficacious and easy to use in preterm neonates with mild to moderate respiratory distress.

Atraumatic Insufficiency Fractures of the Tarsal Bones - An Unusual Cause of Recurrent Heel Pain in a Patient with Rheumatoid Arthritis: A Case Report

The incidence of insufficiency fractures is approximately 1% in rheumatoid arthritis patients. The predisposing factors are chronic inflammation, skeletal deformities, biomechanical stresses and osteoporosis. The medications used in the treatment of rheumatoid arthritis such as Glucocorticosteroids and Methotrexate also contribute to the development of osteoporosis and insufficiency fractures. A 68-year old lady who was suffering from rheumatoid arthritis and on long term Methotrexate was seen in the outpatient clinic with recurrent episodes of heel pain. Examination revealed diffuse tenderness around the heel with full range of ankle movements but painful limitation of subtalar joint movements. Radiographic examination of the ankle showed a highly suspicious fracture of the calcaneus and confirmed on MRI as an insufficiency fracture. She was treated successfully with oral bisphosphonates and moon boot brace. She presented after two years with recurrent episodes of heel pain. The plain radiograph and MRI scan confirmed an insufficiency fracture of the talus. She was treated non-operatively with intravenous Zolendronic acid and bracing. In chronic rheumatoid arthritis patients especially on Methotrexate and Glucocorticoids a high index of suspicion of insufficiency fractures should be considered if they present with bone pain. MRI scan is the investigation of choice and is conclusive.

Pathways to care in children- perspectives from a child guidance clinic in South India

PURPOSE

In India the pathways to care in children with mental health problems remain relatively unexplored. Investigating the factors that drive the pathway will help determine interventions and also draft policies for a streamlined Child and adolescent mental health service.

METHOD

Children who attended the Child Guidance Clinic sampled by WHO Pathways Encounter questionnaire. Statistical tests applied to find key influencers like gatekeepers, intermediate points of care, symptoms initiating referral, duration of untreated illness, time to arrive at appropriate care and primary diagnosis.

RESULTS

The most common diagnostic category was externalizing disorder 51(37.5 %). The gatekeepers identified were 111(81.6 %) Parents/Relatives/Guardians and teachers 25 (18.3 %). Academic concerns identified by teachers took a mean of 72 months (30.271) to arrive at appropriate care versus 50.4 months (23.18) when identified by Parents/Relatives/Guardians group. Significant delays were observed with Neurodevelopmental disorders arriving to care with delays up to 130.2 (70.11) months (p < 0.001) and having 64.2 (33.7) months (p < 0.001) duration of untreated illness. Externalizing disorders took a duration of 94.08 (54.17) months (p < 0.001) to arrive to appropriate care and had 54.2 (36.33) months (p < 0.001) duration of untreated illness. Teachers took longer time in detecting the indicators and this caused duration of untreated illness of 73.44 (36.05) months (p < 0.001) and a delay of 128.08 (71.23) months (p < 0.001) to arrive to appropriate care.

CONCLUSIONS

The pathways to care in children are characterized by long duration of untreated illness and undue time to care. Gatekeepers like teachers and intermediary points of care were associated with inadvertent delays along the pathway.

Mortality and morbidity patterns among HIV patients with prognostic markers in a tertiary care hospital in southern India

BACKGROUND

Opportunistic infections are an important cause of morbidity and mortality in persons infected with HIV. In recent years, antiretroviral treatment (ART) and prophylaxis against various other opportunistic infections have contributed to a decrease in AIDS-related mortality. We conducted a study of HIV infected inpatients in our centre to study the various factors contributing to mortality in HIV/AIDS patients and to study the role of antiretroviral drugs in increasing longevity.

METHOD

We retrospectively reviewed the medical records of HIV/AIDS patients who were admitted to a tertiary care hospital from 1 January 2005 to 28 February 2006. Socio demographic information, CD4 lymphocyte counts (wherever available); diagnoses at discharge, incidence of opportunistic infections in patients and final outcome of the patients were collected.

RESULTS

There was no difference in mean age between the patients who died and those who are surviving. Body weight was comparatively lower for the patients who died than the survivors. Albumin levels were significantly lower among those who died (0.56 ± 1.29 versus 2.73 ± 1.13). CD4 counts did not predict a worse prognosis. History of fever (76.7% versus 53.17%) and weight loss (56.7% versus 33.33%) predictably pointed to a bad prognosis. On the brighter side, administration of specific therapy which included Lamivudine was associated with a better outcome (OR - 0.07, p = 0.004) than any other combination of ART.

CONCLUSION

The above findings could be a rough guide for evaluating the status of HIV/AIDS patients who cannot afford frequent medical investigations in developing countries. Moreover as in our study, it was found that CD4 count was not a very reliable marker for the prognosis in such patients. A broader study could be a clue to a more cost-effective and cheaper alternative mode of assessment for HIV/AIDS patients in developing countries where medical facilities are not just unaffordable but also scanty.

Electrically injected 1.64µm emitting In0.65Ga0.35As 3-QW laser diodes grown on mismatched substrates by MOVPE

We report the characteristics of the strained In_0.65Ga_0.35As triple quantum well (QW) diode lasers grown by metalorganic vapor phase epitaxy (MOVPE) on lattice-mismatched substrates such as GaAs or Si, by utilizing InP metamorphic buffer layers (MBLs) in conjunction with InAs nanostructure-based dislocation filters. As the lattice-mismatch between the substrate and InP MBL increases, higher threshold current densities and lower slope efficiencies were observed, together with higher temperature sensitivities for the threshold current and slope efficiency. Structural analysis performed by both high-resolution X-ray diffraction (HR-XRD) and transmission electron microscopy indicates graded and/or rougher QW interfaces within the active region grown on the mismatched substrate, which accounts for the observed devices characteristics.

Closed Intramedullary Locking Nailing for Metacarpal Fractures: A Retrospective Study of Sixty-Six Fractures

Introduction: Metacarpal fractures are frequent injuries in the young male working population and the majority are treated non-operatively. There is a growing trend to surgically treat these fractures, with the aim of reducing the deformity and shortening the rehabilitation period. The aim of this retrospective case series is to report on our experience and clinical outcomes of using percutaneous flexible locking nails for the management of displaced metacarpal fractures. This study is a retrospective review of 66 fractures that were managed at our centre over a 7-year period.

Materials and Methods: Records of 60 patients were retrospectively reviewed. Indications for surgery were a displaced metacarpal shaft or neck fracture with associated rotational deformity, or multiple metacarpal fractures. The fracture was reduced by closed manipulation, and a flexible pre-bent locked intramedullary nail (1.6mm diameter) was inserted through a percutaneous dorsal antegrade approach, facilitated by a specially designed pre-fabricated awl. The implant was removed at union. Patients were followed-up in clinic until the fracture had united.

Results: The mean union time was seven weeks (range 2 to 22 weeks) and there were nine (14%) delayed unions (>3 months) and no non-unions. The nail had migrated in three cases (5%) and caused skin impingement in two cases (3%). There was one infected case (2%). Rotational clinical deformity was evident for two (3%) cases.

Conclusion: The use of a minimally-invasive locked intramedullary nailing for unstable metacarpal fractures has a significantly low complication rate, with predictable union times and good functional outcomes.

Use of exhaled nitric oxide in children with bronchial asthma

BACKGROUND

Inflammation is an important aspect of the pathophysiology of bronchial asthma and measurement of inflammatory markers of airways can aid in management. Nitric oxide measurement in exhaled breath is a non-invasive method of determining airway inflammation which can be used in assessing severity and response to treatment in children with bronchial asthma.

METHODS

Thirty children in the age group 6-14 years with previously or newly diagnosed bronchial asthma reporting for the first time to a tertiary care hospital constituted the study group. Assessment was done by history, clinical examination, spirometry and measurement of fractional excretion of nitric oxide (FeNO) before commencement of treatment as per standard guidelines and on follow up at 2 to 4 weeks intervals for a minimum of three times.

RESULTS

There was significant correlation between FeNO values, spirometry parameters and clinical profile in the first visit before the initiation of therapy. Children with higher FeNO in the first visit responded better to Inhaled Corticosteroids (ICS) with good clinical and spirometry responses and fall in FeNO on second visit. However, in subsequent visits no significant correlation was observed between clinical control, FeNO levels and spirometry.

CONCLUSION

High FeNO values at first presentation could give us a clue as to whether or not a child would respond to ICS but FeNO monitoring may not be helpful in long term follow up as various other factors can affect its value.

Measuring paper industry's ecological performance in an imprecise and vague scenario: a fuzzy DEA-based analytical framework

Purpose

Productivity improvement is key to sustainability performance improvements of organizations. In a real-world scenario, the nature of inputs and outputs is likely to be imprecise and vague, leading to complexity in comparing firms' efficiency measurements. Implementation of fuzzy-logic based measurement systems is a method for dealing with such cases. This paper presents a fuzzy weight objective function to solve Data Envelopment Analysis (DEA) CCR model for measuring paper mills' performance in India for 15 years.

Design/methodology/approach

An integrated methodology is proposed to solve DEA models having fuzzy weights. The fuzzy DEA methodology is an extended version of the DEA approach that researchers have used for performance measurement purposes in imprecise and vague scenarios. The ecological performance of the paper industry is evaluated, considering some desirable and undesirable outputs. The effect of non-discretionary input on the performance of a paper mill is also analyzed.

Findings

Analysis suggests that the productivity of the paper industry is improving consistently throughout the period. The comparative evaluation of methods suggests that a diverse cluster of DMUs and integration of DEA with the fuzzy logic increases the diversity in the efficiency score while DEA-DE imitates the results of CCR DEA.

Originality/value

Proposed a fuzzy DEA-based analytical framework for measuring the paper industry's ecological performance in an imprecise and vague scenario. The model is tested on data from the paper industry in a developing country context and comparative performance analysis using DEA, fuzzy DEA and DE algorithm is done.