767 Group & Save- Are They Required for Laparoscopic Appendicectomies?

Aim

Laparoscopic appendicectomy (LA) is the gold standard surgical management of appendicitis. Serious intraoperative complications, including bleeding, are rare, however in the absence of a local established guideline, it is standard practice to send two group and save (G&S) samples prior to theatre. We aimed to review our post-operative transfusion risk for LA and to establish if routine group and save testing is required as part of the preoperative workup.

Method

All patients who underwent a laparoscopic appendicectomy in a single centre were reviewed over a 3-month period (April- June 2020). Data was retrieved from an institutional database and up to date electronic records were reviewed for operative details and transfusion history.

Results

Forty-three appendicectomies performed during audit window, twenty-one of which were laparoscopic. 100% of cases had a single group and save recorded pre-operatively, with 76.2% having a second sample sent, totalling 37 samples. Zero patients in the cohort required a post-operative transfusion. Average cost of a group and save equals £26, a total cost of £962 over a 3-month period.

Conclusion

Whilst a small study, we have illustrated LA to be a safe procedure with zero incidence of blood transfusion. There are clear benefits of producing a local guideline that G&S are not routinely required for LA, including financial and resource savings, potential reduction in theatre delays, and reduction of workload for staff.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Harnessing Smartphone Technology to Improve Patient Engagement: Codesigning and Testing The SecondEars Consultation Audio Recording App for People With Cancer

Background: Oncology consultations can be overwhelming and information-dense. Consultation audio recordings are an effective method to promote patient participation, improve patients' recall and understanding of medical information, and can increase engagement and support through sharing with family and friends. Innovative m-health technologies such as the SecondEars consultation audio recording mobile app provide a patient-designed and controlled audio recording solution while ensuring security and legal protection for clinicians. To ensure the SecondEars app meets the needs of patients, family, clinicians and hospital administrators, the opinions of stakeholders and end users are integral to the concept and study creation, design, and testing processes. Aim: To use key elements of codesign methodology to develop and test SecondEars, a mobile app that allows patients to audio record their consultations within a clinical oncology setting. Methods: The SecondEars app concept began with consumer suggestions that consultation audio recording be used as standard practice of care using patient-driven (use is controlled/determined by patients) technologies. An app solution was conceived and the concept discussed through engagement of consumers as part of the project and research codesign team. Key health service stakeholders comprising representatives from: legal, information technology (IT), clinical service leads, digital strategy, and health information services (HIS), provided project oversight and core legal and data management requirements. The Scrum management framework was used to structure the codesign process during the development and testing phase. Six workshops were run to facilitate further user input with regard to specific app functionality and design. A wireframe version was developed and tested by the codesign team in the final workshop. Feedback was incorporated into a prototype which was circulated for acceptance testing. Results: Twenty people participated in the stakeholder engagement and workshops, comprising: oncology consumers, researchers, IT, HIS, app developers, and oncology health professionals. Key specifications necessitated that SecondEars be patient-driven, secure and confidential, have clear legal guidelines regarding audio recording sharing, be integrated with medical records, and require minimal upfront and ongoing resources. Seven people tested the prototype app during user acceptance testing and gave positive and constructive feedback. A final version of the app was then made available for clinical testing. Conclusion: The SecondEars consultation audio recording app has been successfully created by and for patients. This app gives patients permission and autonomy to audio record and share their consultations responsibly, while maintaining legal protection for clinicians. This app is currently being tested in a clinical setting prior to conducting an implementation study.

Hepatic Hilar Lymph Node Reactivity at Kasai Portoenterostomy for Biliary Atresia: Correlations With Age, Outcome, and Histology of Proximal Biliary Remnant

We hypothesized that if infection is the proximate cause of congenital biliary atresia, an appropriate response to antigen would occur in lymph nodes contiguous with the biliary remnant. We compared the number of follicular germinal centers (GC) in 79 surgically excised hilar lymph nodes (LN) and 27 incidentally discovered cystic duct LNs in 84 subjects at the time of hepatic portoenterostomy (HPE) for biliary atresia (BA) to autopsy controls from the pancreaticobiliary region of non-septic infants >3 months old at death. All 27 control LN lacked GC, a sign in infants of a primary response to antigenic stimulation. GC were found in 53% of 106 LN in 56 of 84 subjects. Visible surgically excised LN contiguous with the most proximal biliary remnants had 1 or more well-formed reactive GC in only 26/51 subjects. Presence of GC and number of GC/LN was unrelated to age at onset of jaundice or to active fibroplasia in the biliary remnant but was related to older age at HPE. Absent GC in visible and incidentally removed cystic duct LNs predicted survival with the native liver at 2 and 3 years after HPE, P = .03, but significance was lost at longer intervals. The uncommon inflammatory lesions occasionally found in remnants could be secondary either to bile-induced injury or secondary infection established as obstruction evolves. The absence of consistent evidence of antigenic stimulation in LN contiguous with the biliary remnant supports existence of at least 1 major alternative to infection in the etiology of biliary atresia.

Surface-enhanced charge-density-wave instability in underdoped Bi2Sr(2-x)La(x)CuO(6+δ)

Neutron and X-ray scattering experiments have provided mounting evidence for spin and charge ordering phenomena in underdoped cuprates. These range from early work on stripe correlations in Nd-LSCO to the latest discovery of charge-density-waves in YBa2Cu3O(6+x). Both phenomena are characterized by a pronounced dependence on doping, temperature and an externally applied magnetic field. Here, we show that these electron-lattice instabilities exhibit also a previously unrecognized bulk-surface dichotomy. Surface-sensitive electronic and structural probes uncover a temperature-dependent evolution of the CuO2 plane band dispersion and apparent Fermi pockets in underdoped Bi2 Sr(2-x) La(x) CuO(6+δ) (Bi2201), which is directly associated with an hitherto-undetected strong temperature dependence of the incommensurate superstructure periodicity below 130 K. In stark contrast, the structural modulation revealed by bulk-sensitive probes is temperature-independent. These findings point to a surface-enhanced incipient charge-density-wave instability, driven by Fermi surface nesting. This discovery is of critical importance in the interpretation of single-particle spectroscopy data, and establishes the surface of cuprates and other complex oxides as a rich playground for the study of electronically soft phases.

Cohort analysis of directly observed treatment outcomes for tuberculosis patients in urban Pakistan

BACKGROUND

This quasi-experimental cohort study aimed to evaluate World Health Organization (WHO) defined tuberculosis (TB) treatment outcomes for patients under directly observed treatment at a health facility (clinic DOT) or at home (family DOT) in urban Pakistan.

METHODS

We enrolled 582 sputum smear-positive TB patients being treated by either clinic DOT (n = 295) or family DOT (n = 287) in 11 treatment centres. Patients and/or family members were interviewed for baseline measurements. WHO-defined treatment outcomes were evaluated at the end of treatment. Proportions of 'cured' patients were computed. A log-binomial model was used to evaluate the associations of various factors with 'cured' status.

RESULTS

The proportion of 'cured' patients was respectively 66% and 34% in the clinic DOT and family DOT groups (risk difference 0.32; 95%CI 0.24-0.39). Patients on clinic DOT were more likely to achieve cure (adjusted relative risk [RR(adj)] 1.85; 95%CI 1.43-2.39) than those on family DOT, as were patients satisfied with their health care worker's attitude (RR(adj) 5.73; 95%CI 2.54-12.96).

CONCLUSION

Clinic DOT nearly doubled the proportion of cured patients compared to family DOT. Efforts to improve care-provider attitudes to enhance patient satisfaction, and effective implementation of the WHO's public-private mix approach, may enhance TB control in this and similar settings.

Myelodysplastic syndrome after autologous peripheral blood stem cell transplantation for multiple myeloma

Long-term survivors after autologous peripheral blood stem cell transplantation (APBSCT) for lymphoma or Hodgkin's disease are known to have a high risk of developing myelodysplastic syndrome (MDS), but the risk of MDS is not clear for patients transplanted for myeloma. We reviewed the outcomes for 82 myeloma patients who underwent APBSCT at our center. The group included 47 men and 35 women of median age 56 years (range: 37-74 years). Median time from diagnosis to APBSCT was 8.2 months (range: 2.6-86.1 months). Before coming to transplantation, 28% had received oral melphalan (MEL), 98% received other chemotherapy and 34% received radiation. A single APBSCT was provided for 68, and 32% underwent APBSCT more than once. High-dose MEL alone was used as the preparative regimen for 83%, and the remainder received at least one APBSCT with a more intensive preparative regimen. Ten patients (12%) developed MDS. The 5-year cumulative incidence is 18% (95% confidence interval, 9-30%). There were no demographic factors associated with an increased risk of developing MDS. Median survival after the diagnosis of MDS was 18 months. There is a relatively high risk of MDS after APBSCT for myeloma, and optimal therapy has not been established for these patients.

Review of specialist dietitian services in patients with inherited metabolic disease in the United Kingdom

INTRODUCTION

Dietary management forms the mainstay of treatment for many inherited metabolic diseases (IMDs) and specialist dietitians play a crucial role in the multi-disciplinary core team for these patients. Professional concerns have been expressed that the current clinical workforce is inadequate for meeting current and future service demands. The aim of this work was to describe the provision of specialist dietetics to patients with IMD as part of a national needs assessment and review.

MATERIALS AND METHODS

The 24 main specialist providers and 27 specialist dietitians were surveyed by a questionnaire. A focus group of three specialist dietitians was also held to explore the roles of specialist dietitians in greater depth.

RESULTS

Responses were received from all 24 specialist service providers and 63% of 27 specialist dietitians. The majority of service providers (92%) have specialist dietitians, but only eight services had more than one whole time equivalent (33%). Key roles were management of complex dietary regimens, prevention and management of metabolic crises, education, co-ordination of care, clinical audit and research. Although highly qualified, there is currently no clear formal career structure or training pathway for dietitians in IMDs.

CONCLUSION

Specialist dietitians have important clinical and leadership roles in managing IMD but specialist services are thinly spread. There is a need for access to formal education, training and support programmes. The clinical workforce needs expansion to provide more comprehensive and equitable services.

Diabetes knowledge, beliefs and practices among people with diabetes attending a university hospital in Karachi, Pakistan

A structured questionnaire on knowledge, beliefs and practices regarding diabetes was administered to 199 persons with diabetes (92.5% type 2) attending the Aga Khan University Hospital, Karachi. Mean age [standard deviation (SD)] was 53 (11) years. Mean duration of diabetes (SD) was 8 (7) years in men and 9 (6) years in women. Men had a significantly better knowledge score than women (P = 0.02); there was no significant difference in the beliefs and practices scores. Scores were classed as good (> 60%) in only 13.6% of participants for knowledge, 17.6% for beliefs and 11.2% for practices. About 38% of the participants had received education on diabetes care.

Identification of the growth arrest and DNA damage protein GADD34 in the normal human heart and demonstration of alterations in expression following myocardial ischaemia

Growth arrest and DNA damage protein 34 (GADD34) is a multifunctional protein upregulated in response to cellular stress and is believed to mediate DNA repair and restore protein synthesis. In the present study we have examined GADD34 immunoreactivity in human myocardial tissue at defined survival times following cardiac arrest and determined alterations in expression following ischaemia. In the normal human heart, GADD34 immunoreactivity was generally intense and present within most cells. GADD34 immunoreactivity was downregulated in tissue displaying ischaemic damage and remained intense in adjacent non-infarcted tissue. Unlike brain, GADD34 was not found to be upregulated in the peri-infarct zone. Cells displaying apoptotic changes were located in regions displaying reduced GADD34 immunoreactivity. In the brain, it is thought that GADD34 supports re-initiation of protein synthesis following ischaemia. Similarly, GADD34 may perform important functions in cardiac tissue in response to ischaemia.

Fat intakes of children with PKU on low phenylalanine diets

BACKGROUND

As part of a study on the effects of a fat-supplemented phenylalanine (phe)-free protein substitute on the fatty acid status of children with phenylketonuria (PKU), the adequacy of the diets of children aged 1-10 years for fat and essential fatty acids (EFA) was assessed.

METHODS

Subjects randomized in a 1 : 1 ratio to a phe-free protein substitute supplemented with EFA (test-treatment group) or a phe-free, fat-free protein substitute (control group) for 20 weeks. 3-day semi-weighed records of food intakes collected at the end of the study period.

RESULTS

Total fat and alpha-linolenic acid (alpha-LA) intakes were found to be poor in the control group (n = 19). Those in the test-treatment group (n = 24) had higher fat and EFA intakes (P < 0.05), bringing intakes closer to population norms. The youngest children (<5 years of age) in the control group appeared to be especially vulnerable to poor fat intakes because of the restricted diversity of their diets and, regardless of age, alpha-LA intakes by this group were poor compared with the non-PKU population.

CONCLUSIONS

The quantity and quality of fat in the diets of children with PKU, in particular young children, should be given careful consideration in trying to optimize the ratio of linoleic acid: alpha-LA in their diets and in satisfying the requirements of this group for fat and alpha-LA.

Health and social impacts of improved stoves on rural women: a pilot intervention in Sindh, Pakistan

To assess the acceptability, social and health impacts of improved stoves among women. A cross-sectional study was conducted from April to May 2002 among households using improved stoves in the two villages of District Thatta and Hyderabad, Sindh, Pakistan. A questionnaire was administered to 45 women using improved stoves named Smoke Free Stoves (SFS). The same questionnaire was administered to a sample of 114 women, using Traditional Stoves (TS). Carbon monoxide (CO) levels were measured in a sample of both groups. Multivariate analysis was carried out to adjust for confounders. In addition, focus group discussions (FGDs) were conducted to evaluate the perception of women regarding acceptability and impact of SFS on women. A majority of women reported that SFS produce less smoke and have a beneficial impact on their health. In the multivariate analysis, symptoms of dry cough (AOR=0.61; 95% CI 0.26-1.41), sneezing (AOR=0.54; 95% CI 0.22-1.30) and tears while cooking (TWC) (AOR=0.51; 95% CI 0.21-1.21) are less likely to occur in women using SFS compared to TS. However, the results were not statistically significant possibly due to the small sample. The mean (+/-s.e.) CO levels were 15.4+/-3.4 ppm in SFS and 28.5+/-5.7 ppm in TS kitchens with a mean difference of -13.1 (95% CI -29.5 and 3.2). The results indicate a trend favorable for SFS and suggest that a larger scale project should be undertaken to reach to a definitive conclusion, ideally using a longitudinal design.

PRACTICAL IMPLICATIONS

In order to enhance IAQ in kitchens in developing regions of the world stoves for burning of biomass should be constructed in a way that the emission of fuel gases are low. In this way the risk of negative health effects will be reduced.

Identification and characterization of IS1112 and IS1113 insertion element sequences in Xanthomonas oryzae pv. oryzae

Two new insertion sequences (IS1112 and IS1113) were identified in the genome of Xanthomonas oryzae pv. oryzae, the causal agent of bacterial blight of rice. Three copies of IS1112 were trapped, one containing 1052-bp and the other two with 1055-bp. They all have 25-bp imperfect inverted repeats with a 3-bp duplication at the site of insertion. They contain an open reading frame (ORF) of 317 and 318 amino acid residues, respectively. IS1113 is 1306-bp, contains 25-bp imperfect terminal inverted repeats, and is flanked by a 9-bp direct repeat at the site of insertion. It contains an ORF of 395 amino acid residues.

Up-regulation of a growth arrest and DNA damage protein (GADD34) in the ischaemic human brain: implications for protein synthesis regulation and DNA repair

GADD34 is a growth arrest and DNA damage inducible gene up-regulated in response to DNA damage, cell cycle arrest and apoptosis. It is thought that GADD34 may play a crucial role in cell survival in ischaemia. GADD34 expression was assessed immunohistochemically in post-mortem human hippocampal tissue obtained from patients surviving for defined periods (0-24 h; 24 h-7 days) after a cardiac arrest and in age-matched control subjects. In control brain, cytoplasm staining in GADD34 immunopositive cells was faint but present throughout the hippocampus and cortex. There was minimal change in GADD34 expression in the group surviving 0-24 h after cardiac arrest. However GADD34 immunostaining was markedly increased in selectively vulnerable regions in the 24 h-7 day survival group. Increased GADD34 staining was present in ischaemic neurones and in some morphologically normal neurones after cardiac arrest. Extensive ischaemic damage was found to correlate with elevated GADD34 immunostaining in the CA1 layer of the hippocampus (**P < 0.0016). In addition, GADD34 was found to colocalize with proliferating cell nuclear antigen in some neurones. The up-regulation of GADD34 in response to global ischaemia in the human brain plus its influence on protein synthesis and DNA repair suggests that this protein may have the potential to influence cell survival.

Risk factors for non-fatal myocardial infarction in young South Asian adults

OBJECTIVE

To determine the risk factors for premature myocardial infarction among young South Asians.

DESIGN AND SETTING

Case-control study in a hospital admitting unselected patients with non-fatal acute myocardial infarction.

METHODS AND SUBJECTS

Risk factor assessment was done in 193 subjects aged 15-45 years with a first acute myocardial infarct, and in 193 age, sex, and neighbourhood matched population based controls.

RESULTS

The mean (SD) age of the subjects was 39 (4.9) years and 326 (84.5%) were male. Current smoking (odds ratio (OR) 3.82, 95% confidence interval (CI) 1.47 to 9.94), use of ghee (hydrogenated vegetable oil) in cooking (OR 3.91, 95% CI 1.52 to 10.03), raised fasting blood glucose (OR 3.32, 95% CI 1.21 to 8.62), raised serum cholesterol (OR 1.67, 95% CI 1.14 to 2.45 for each 1.0 mmol/l increase), low income (OR 5.05, 95% CI 1.71 to 14.96), paternal history of cardiovascular disease (OR 4.84, 95% CI 1.42 to 16.53), and parental consanguinity (OR 3.80, 95% CI 1.13 to 1.75) were all independent risk factors for acute myocardial infarction in young adults. Formal education versus no education had an independently protective effect on acute myocardial infarction (OR 0.04, 95% CI 0.01 to 0.35).

CONCLUSIONS

Tobacco use, ghee intake, raised fasting glucose, high cholesterol, paternal history of cardiovascular disease, low income, and low level of education are associated with premature acute myocardial infarction in South Asians. The association of parental consanguinity with acute myocardial infarction is reported for the first time and deserves further study.

Macrovascular complications and their associated factors among persons with type 2 diabetes in Karachi, Pakistan--a multi-center study

OBJECTIVE

To assess the prevalence of macrovascular complications and factors associated with these complications among persons with Type 2 diabetes.

METHODS

A multi-center, cross-sectional survey was conducted in three diabetes clinics of Karachi from November 2000 to April 2001. Six hundred and seventy-two persons were interviewed to determine the prevalence of ischemic heart disease (IHD), cerebrovascular disease (CVA) and diabetic foot (DF). Demographic data and co-variables obtained include age, sex, duration of diabetes, body mass index (BMI), smoking status, exercise habits and history of hypertension (HTN).

RESULTS

Overall, 26.4%, 6.8% and 3.9% of individuals had IHD, CVA and DF respectively. Multiple logistic regression analysis showed that subjects having IHD were more likely to have HTN (AOR=1.88, 95% CI 1.31-2.69), not performing regular exercise (AOR = 2.09, 95% CI 1.39-3.17) and be current smokers (AOR = 1.85, 95% CI 1.10-3.10) Subjects having CVA were more likely to have diabetes for more than 5 years (AOR = 1.94, 95% CI 0.97-3.87). Males were more prone than females to have DF (AOR = 3.48, 95% CI 1.46-8.31). Those who had DF were more likely to have diabetes for more than 5 years (AOR = 3.29, 95% CI 1.09-9.89) and of reporting current smoking (AOR = 4.01, 95% CI 1.49-10.71).

CONCLUSION

Large proportions of persons with Type 2 diabetes were suffering from preventable macrovascular complications in Karachi, Pakistan. There is a need to develop risk factor modification interventions to reduce the impact of long-term complications.

Animal disease surveillance: prospects for development in Pakistan

Surveillance is a continuous and systematic process of collection, consolidation, analysis, interpretation and dissemination of relevant information on the occurrence of health problems. Data from surveillance can be used to calculate the incidence and prevalence of events, to categorise disease distribution by relevant characteristics, to guide investigations into the occurrence of epidemic and endemic disease, and to contribute essential information for the design and evaluation of effective disease prevention and control programmes. Disease surveillance systems should also respond to the information needs of government agencies, agribusiness, academia, producers and consumers. However, in most developing countries, including Pakistan, animal disease surveillance systems are not well developed, and do not produce a desirable quality of information on disease status and trends. In this paper, the authors describe various facets of a generic surveillance system and propose a structure for a surveillance system at district level. Such systems have been designed and implemented for public health surveillance in a number of countries, and may be developed to meet the needs of veterinary public health.

Proliferation and neuronal differentiation of mitotically active cells following traumatic brain injury

Recent studies have identified endogenous neural stem cells in adult rodent brains. The present study characterizes the early response of mitotically active cells in the brain to traumatic brain injury. Animals were subjected to lateral fluid percussion injury and sacrificed at various times after injury. To examine increases in cell proliferation animals were injected with the mitotic marker bromodeoxyuridine (BrdU) 24 h before sacrifice. Increased numbers of mitotically active cells were observed at 2 days in the subgranular zone (SGZ) and the subependymal zone (SEZ) under the injury site. To characterize the differentiation potential of these cells, animals were injected with BrdU 18 and 20 h after injury, then sacrificed at multiple time points after injury. Histologically, co-localization with betaIII-tubulin (neuronal marker) and BrdU was evident at 10 and 15 days postinjury in the SGZ. Flow cytometry analysis was used to quantitatively assess neurogenesis in the SEZ. Animals were sacrificed 1, 5, or 10 days after injury and tissue sections extracted, grown in tissue culture for 24 h, fixed, and stained for nestin and betaIII-tubulin to identify newly formed neurons. The percentage of cells expressing both markers was determined using flow cytometry analysis. There was a significant increase in newly differentiated neurons by 10 days postinjury in the SEZ. Thus, we conclude that traumatic brain injury stimulates an increase in proliferation of endogenous neural stem/progenitor cells and that a significant number of these express a neuronal marker. This response may be the brain's way of trying to heal itself after injury.

Clinical decision making Part I: errors of commission and omission

Clinical decision making refers to any act of diagnosis that leads to a decision regarding prognosis, treatment, referral or counseling. It has long been recognized that diagnostic probabilities influence perceptions and judgements in medical practice. However, so do ethical values affect clinical judgements, even if these lead to adverse consequences: for example, to judge a well person sick is considered "more ethical" than to judge a sick person well. This dilemma confronts us also when having to choose between what are called Type 1 and Type 2 errors, and the consequences of either may be serious. Other factors that should be taken into account, as they can affect the "pretest likelihood" or "prior probability" of disease and the error rates obtained, include the individual circumstances of the patient (e.g. socioeconomic background), the organizational setting (e.g. patient volume, cultural practices and norms), and system differences (e.g. fee for service versus salaried service). In Part II of this two-part series,we explore in greater depth the mathematical basis for why various diagnostic procedures perform differently in different settings.

Factors affecting utilization of antenatal care among reproductive age group women (15-49 years) in an urban squatter settlement of Karachi

OBJECTIVES

To describe the socio-demographic characteristics and utilization pattern of antenatal care of reproductive age group women (15-49 years) in an urban squatter settlement of Karachi and to assess and compare the knowledge on antenatal care between women who received and those who did not receive antenatal care.

METHODS

A community-based cross sectional survey was conducted and a sample of 323 women was taken through systematic sampling. Two hundred ninety five (295) women were interviewed and 28 were excluded, as they never experienced a pregnancy. Socio-demographic characteristics and knowledge about antenatal care were compared on the basis of having received and not having received antenatal care, utilizing bivariate and multivariate analysis.

RESULTS

Multivariate logistic regression analysis showed that higher income women were twice likely to use antenatal care services (AOR = 2.11 95% CI 1.14-3.89) than those of lower income. Women receiving antenatal care were more knowledgeable about the importance of dietary protein (AOR = 1.97 95% CI 1.16-3.33), intake of green leafy vegetables for the prevention of anemia (AOR = 2.34 95% CI 1.33-4.11), and reporting danger signs (AOR = 2.25 95% CI 1.07-4.74).

CONCLUSION

Women of reproductive age need to recognize the importance of receiving antenatal care in the community. Uplifting the socio-economic status and literacy rate of women is required to provide community based education. There is a potential need to increase nutrition education, highlighting the importance of iron supplementation, appropriate food during pregnancy and recognition of signs and symptoms and danger signs in pregnancy.

Evaluation of a water, sanitation, and hygiene education intervention on diarrhoea in northern Pakistan

OBJECTIVE

Inadequate water and sanitation services adversely affect the health and socioeconomic development of communities. The Water and Sanitation Extension Programme (WASEP) project, undertaken in selected villages in northern Pakistan between 1997 and 2001, was designed to deliver an integrated package of activities to improve potable water supply at village and household levels, sanitation facilities and their use, and awareness and practices about hygiene behaviour.

METHODS

A case-control study was conducted during July-September 2001 to evaluate whether, after selected confounders were controlled for, children aged <6 years with diarrhoea were more or less likely to reside in villages that participated in the project than in villages that did not participate. Descriptive and logistic regression analyses were performed.

FINDINGS

Children not living in WASEP villages had a 33% higher adjusted odds ratio for having diarrhoea than children living in WASEP villages (adjusted odds ratio, 1.331; P<0.049). Boys had 25% lower odds of having diarrhoea than girls (adjusted odds ratio, 0.748; P<0.049). A 2.6% decrease was found in the odds of diarrhoea for every yearly increase in the mother's age (adjusted odds ratio, 0.974; P<0.044) and a 1.4% decrease for every monthly increase in the child's age (adjusted odds ratio, 0.986; P<0.001).

CONCLUSIONS

The findings in this study may help refine the approach to future water, sanitation, and hygiene initiatives in northern Pakistan. The integrated approach taken by WASEP, which incorporates engineering solutions with appropriate education to maximize facility usage and improve hygiene practices, is a useful example of how desired health benefits can be obtained from projects of this type.

Effect of ibuprofen and acetaminophen on postexercise muscle protein synthesis

We examined the effect of two commonly consumed over-the-counter analgesics, ibuprofen and acetaminophen, on muscle protein synthesis and soreness after high-intensity eccentric resistance exercise. Twenty-four males (25 +/- 3 yr, 180 +/- 6 cm, 81 +/- 6 kg, and 17 +/- 8% body fat) were assigned to one of three groups that received either the maximal over-the-counter dose of ibuprofen (IBU; 1,200 mg/day), acetaminophen (ACET; 4,000 mg/day), or a placebo (PLA) after 10-14 sets of 10 eccentric repetitions at 120% of concentric one-repetition maximum with the knee extensors. Postexercise (24 h) skeletal muscle fractional synthesis rate (FSR) was increased 76 +/- 19% (P < 0.05) in PLA (0.058 +/- 0.012%/h) and was unchanged (P > 0.05) in IBU (35 +/- 21%; 0.021 +/- 0.014%/h) and ACET (22 +/- 23%; 0.010 +/- 0.019%/h). Neither drug had any influence on whole body protein breakdown, as measured by rate of phenylalanine appearance, on serum creatine kinase, or on rating of perceived muscle soreness compared with PLA. These results suggest that over-the-counter doses of both ibuprofen and acetaminophen suppress the protein synthesis response in skeletal muscle after eccentric resistance exercise. Thus these two analgesics may work through a common mechanism to influence protein metabolism in skeletal muscle.

[An intervention to improve diabetes control in Chile]

OBJECTIVE

Previous research has shown that controlling blood glucose improves short-term and long-term outcomes among patients who have either type 1 or type 2 diabetes. The objective of this study was to investigate, in a developing country, the effectiveness of an intervention that included patient education, self-monitoring of blood glucose, and determination of the level of glycosylated hemoglobin (HbA1c).

METHODS

The patients were grouped into three categories, taking into account such clinical manifestations as the duration of their diabetes, its treatment, and their hospitalization history. After the inclusion and exclusion criteria were applied, the persons were randomly assigned to two groups. One group (210 patients) received the educational intervention, and the control group (206 patients) received customary care. The intervention group received educational information needed for self-monitoring of blood glucose and for the self-evaluation of positive and negative behaviors related to metabolic control of the disease.

RESULTS

The two groups were similar with respect to age (mean of 52.3 and 50.5 years) and to the proportion of patients with type 1 diabetes (13.8% and 16.0%). There were no initial differences in the average concentration of HbA1c in the two groups (8.9% +/- 0.1% and 8.9% +/- 1.4%). A total of 50 persons dropped out of the study, 14.8% of those in the intervention group and 9.2% of those in the control group. In the intervention group, compliance with dietary recommendations increased by 43.5%, from 57.5% at the beginning of the study to 82.5% at the end (P < 0.001); in the control group there was also a change but it was not significant. Although patients with a high initial HbA1c concentration were underrepresented in this study, the average HbA1c concentration declined significantly in the intervention group (-0.4% +/- 1.1%, P = 0.001) but not in the control group (-0.1% +/- 0.1%).

CONCLUSIONS

In one developing country, educating patients about diabetes helped improve metabolic control, a fact that can be attributed mainly to the intervention's positive impact on those persons' diet.

Skeletal muscle PGF(2)(alpha) and PGE(2) in response to eccentric resistance exercise: influence of ibuprofen acetaminophen

PGs have been shown to modulate skeletal muscle protein metabolism as well as inflammation and pain. In nonskeletal muscle tissues, the over the counter analgesic drugs ibuprofen and acetaminophen function through suppression of PG synthesis. We previously reported that ibuprofen and acetaminophen inhibit the normal increase in skeletal muscle protein synthesis after high intensity eccentric resistance exercise. The current study examined skeletal muscle PG levels in the same subjects to further investigate the mechanisms of action of these drugs in exercised skeletal muscle. Twenty-four males (25 +/- 3 yr) were assigned to 3 groups that received the maximal over the counter dose of ibuprofen (1200 mg/d), acetaminophen (4000 mg/d), or a placebo after 10-14 sets of 10 eccentric repetitions at 120% of concentric 1 repetition maximum using the knee extensors. Preexercise and 24 h postexercise biopsies of the vastus lateralis revealed that the exercise-induced change in PGF(2alpha) in the placebo group (77%) was significantly different (P < 0.05) from those in the ibuprofen (-1%) and acetaminophen (-14%) groups. However, the exercise-induced change in PGE(2) in the placebo group (64%) was only significantly different (P < 0.05) from that in the acetaminophen group (-16%). The exercise-induced changes in PGF(2alpha) and PGE(2) were not different between the ibuprofen and acetaminophen groups. These results suggest that ibuprofen and acetaminophen have a comparable effect on suppressing the normal increase in PGF(2alpha) in human skeletal muscle after eccentric resistance exercise, which may profoundly influence the anabolic response of muscle to this form of exercise.

Moving from concepts to study types approaches to classifying scientific inquiry

There is no such concept as "the ideal research method". Most study types are understood and taught in a relative vacuum without appreciating their philosophical context. However, to achieve an optimal approach is more a matter of resolving the congruence between research purpose and method. Proper location of research methods within a theoretical framework is therefore important, otherwise the resulting over-simplification will eventually lead to inappropriate use of study types. Designing any type of study encompasses the process of identification, exploration and explanation, and utilizes concepts such as manipulation, sampling, replication and time dimensions. Medical research has borrowed study types both from Epidemiology and Social Sciences and practiced as observational and experimental inquiries, and we offer in the present review a framework within which these various types may be understood.

Impaired neuronal plasticity in transgenic mice expressing human apolipoprotein E4 compared to E3 in a model of entorhinal cortex lesion

The apolipoprotein E (APOE) epsilon 4 allele is a major risk factor for late-onset familial and sporadic Alzheimer's disease (AD) and is associated with a poor outcome after brain injury. Each apoE isoform is suggested to have differential effects on neuronal repair mechanisms within the CNS. In the present study, APOE genotype influence on the immediate response to injury and subsequent repair process was examined in a line of transgenic APOE mice possessing human APOE gene insertions (epsilon 3 and epsilon 4). Quantification of synaptophysin and GAP-43 immunoreactivity was used to measure the extent of degeneration and regeneration after entorhinal cortex lesion (ECL). Progressive neurodegenerative decline occurred in the ipsilateral dentate gyrus until day 28 post-ECL which was more severe in APOE epsilon 3 mice compared to APOE epsilon 4 mice. By day 90 post-ECL compensatory sprouting and reactive synaptogenesis had taken place in the dentate gyrus of APOE epsilon 3 mice such that GAP-43 and synaptophysin immunoreactivity had returned to prelesion levels. In contrast, APOE epsilon 4 mice displayed significant deficits in synaptophysin and GAP-43 immunostaining compared to the APOE epsilon 3 mice (P < 0.05). Expansion of the inner molecular layer (IML) was used as a measure of the sprouting index from the commissural-associational pathway and by day 90 post-ECL the IML width in APOE epsilon 3 mice had increased by 45% but only 20% in APOE epsilon 4 mice (P < 0.0001). ApoE immunoreactivity was increased within the neuropil and glia to the same extent in APOE epsilon 3 and APOE epsilon 4 mice post-ECL. There was no significant difference in the deposition and clearance of degeneration products between APOE epsilon 3 and epsilon 4 mice post-ECL. These results indicate that neuronal plasticity is impaired in transgenic mice possessing human APOE epsilon 4 alleles compared to APOE epsilon 3. These isoform-specific differences in plasticity may relate to the severity of AD and poor, long-term recovery after head injury in APOE epsilon 4 individuals.

The paired homeodomain protein DRG11 is required for the projection of cutaneous sensory afferent fibers to the dorsal spinal cord

Cutaneous sensory neurons that detect noxious stimuli project to the dorsal horn of the spinal cord, while those innervating muscle stretch receptors project to the ventral horn. DRG11, a paired homeodomain transcription factor, is expressed in both the developing dorsal horn and in sensory neurons, but not in the ventral spinal cord. Mouse embryos deficient in DRG11 display abnormalities in the spatio-temporal patterning of cutaneous sensory afferent fiber projections to the dorsal, but not the ventral spinal cord, as well as defects in dorsal horn morphogenesis. These early developmental abnormalities lead, in adults, to significantly attenuated sensitivity to noxious stimuli. In contrast, locomotion and sensori-motor functions appear normal. Drg11 is thus required for the formation of spatio-temporally appropriate projections from nociceptive sensory neurons to their central targets in the dorsal horn of the spinal cord.

Alterations in ApoE and ApoJ in Relation to Degeneration and Regeneration in a Mouse Model of Entorhinal Cortex Lesion

Apolipoproteins are primarily involved in the transport of lipid and cholesterol within the central nervous system (CNS) and are thought to play a role in synaptic remodeling, repair, and regeneration after brain injury. In the present study, alterations in apolipoproteins E (apoE) and J (apoJ) were examined in the molecular layers of the dentate gyrus after unilateral chemical lesioning of the entorhinal cortex (ECL), at days 0, 1, 3, 7, 28, and 90 days following injury. Alterations in immunostaining for these proteins were assessed in relation to accumulation of silver-labeled degeneration products and alterations in synaptophysin and GAP-43 immunoreactivity. Quantitative analysis of synaptophysin and GAP-43 immunostaining highlighted synaptic loss and fiber degeneration initially (3-7 days post-ECL), with subsequent terminal sprouting and reactive synaptogenesis occurring at longer survival periods (28-90 days post-ECL). Increased apoE and apoJ immunoreactivity was evident first within the neuropil (*P < 0.05 and **P < 0.01) followed by intense glial staining by day 7 post-ECL. By day 28 apoE and apoJ immunostaining had returned almost to baseline levels. However, at day 90 post-ECL, neuropil apoE and apoJ immunoreactivity was dramatically increased compared to contralateral levels (**P < 0.01 and ***P < 0.0001, respectively). Silver-labeled degeneration products were found to be in abundance at day 3 postlesion; however, by day 7 this was reduced leaving only a thin band of material within the MML and at day 90 post-ECL, dentate silver staining was similar to that of controls. The results indicate that apoE and apoJ are upregulated after injury and parallel clearance of cholesterol and lipid debris from the site of injury. This coordinated alteration in apolipoproteins may redistribute lipid material to sprouting fibers to promote neurite extension and may play an important role in long-term plasticity changes following injury.

Why a research study needs a design?

Medical research requires as much attention to management as it does to science. Effective research depends first upon the thoughtful statements of purpose and objectives, and related research questions. These important initial steps in turn drive key decisions regarding study type, plans for analyses and competent implementation within bounded timeframes and budgets. The research endeavour materializes by selecting appropriate study types based on coherent research questions, appropriate data collection, and ultimately concludes by drawing inferences on the basis of properly planned analyses. This article reviews these principles and inter-relationships.

Community health sciences and the legacy of Ibn Ridwan at the Aga Khan University

This report briefly describes the Aga Khan University with particular reference to the Department of Community Health Sciences which was recently rehoused in the new Ibn Ridwan building. The building was named after Ibn Ridwan because of his significant contribution to community health, and some details of his life are given.

Outcome of early hepatic portoenterostomy for biliary atresia

BACKGROUND

The outcome of the hepatic portoenterostomy (Kasai) procedure for biliary atresia is improved when it is performed before 90 days of age. However, it is not known whether intervention before 30 days is better than intervention between 30 and 90 days.

METHODS

The authors reviewed the records of all patients seen by the Pediatric Gastroenterology Service at St. Louis Children's Hospital from 1984-1999 to ascertain the outcome of patients who underwent Kasai procedure before or after 30 days of age.

RESULTS

Of 92 patients with biliary atresia treated at St. Louis Children's Hospital over 15 years, 9 underwent the Kasai procedure before 30 days of age. Liver transplantation was necessary in 77.8% of these patients at a mean age of 11.0 +/- 4.26 months, as compared with 53.4% at 32.14 +/- 7.14 months for the remainder of the patients who underwent the procedure after 30 days of age.

CONCLUSIONS

Although these data suggest that outcomes are worse for patients who undergo the procedure before 30 days of age, they may reflect a difference in the pathogenesis of biliary atresia that brings it to clinical attention earlier and may provide further evidence that biliary atresia is a phenotype for a number of distinct underlying disease processes.

Perspective on variables in medical research

Research concepts cannot be materialized until and unless study variables are carefully selected and clearly defined. However, emphasis on variables is not limited to data collection. It should be envisioned from the start that the contents of the variables recorded are congruent with the statistical analysis suggested. These two processes require a comprehensive understanding of variables in epidemiology and biostatistics disciplines. In this article classifications are discussed keeping in view their utility in medical research.

Community health sciences and the legacy of Ibn Ridwan at the Aga Khan University

This report briefly describes the Aga Khan University with particular reference to the Department of Community Health Sciences which was recently rehoused in the new Ibn Ridwan building. The building was named after Ibn Ridwan because of his significant contribution to community health, and some details of his life are given.

The proposition: an insight into research

Propositions form the basis for scientific research. The validity of a research study is, to a large extent, evaluated on the criteria of its propositions. For internal validity, study propositions provide information regarding precision of definitions, measurements, associations, confounding factors etc. that are considered in research. While for external validity, propositions form the premise for the deduction of inferences. The aim of this article is to help readers understand the propositions that are made in research. This article discusses those propositions, which are relevant to medical research.

The role of apolipoprotein E in Alzheimer's disease, acute brain injury and cerebrovascular disease: evidence of common mechanisms and utility of animal models

The epsilon 4 allele of apolipoprotein E (APOE denotes gene; apoE denotes protein) is a major risk factor for Alzheimer's disease (AD). More recent evidence indicates an association with a poor outcome after acute brain injury including that due to head trauma and intracerebral hemorrhage. APOE gene polymorphism also influences the risk of hemorrhage in cerebral amyloid angiopathy. These diverse brain disorders seem to have some mechanisms in common. The multiplicity of the roles of apoE within the central nervous system is currently being unraveled. For example, apoE can interact with amyloid beta-protein and tau, proteins central to the pathogenesis of AD. In addition to these effects, it is proposed that one of the major functions of apoE is to mediate neuronal protection, repair and remodeling. In all of the different roles proposed, there are marked apoE-isoform specific differences. Although it remains to be clarified which is the most important mechanism(s) in each disorder in which apoE is involved, these isoform specific differences seem to underly a genetically determined susceptibility to outcome from acute brain injury and to AD with APOE epsilon 4 conferring relative vulnerability. This review focuses on apoE research, from clinical studies to animal models, in AD, acute brain injury and cerebrovascular disease and explores the common mechanisms that may explain some of the complex underlying neurobiology.

Evaluating programs to prevent unintentional trauma in Canada: challenges and directions

BACKGROUND

Trauma remains the number one cause of death for people under the age of 44 years and consumes a disproportionate amount of resources. This review describes the spectrum of prevention strategies in Canada, current behavior-oriented trauma prevention initiatives, and evaluations of their effectiveness.

METHODS

A literature search of English language citations in MEDLINE was carried out by using the word "prevention" in conjunction with any of the words "injury," "accident," "trauma," "fall," "collision," and "traffic." Relevant material from bibliographies was also obtained. A comprehensive compilation of local and national prevention programs in Canada was reviewed. Only programs with reported evaluation data were included.

CONCLUSION

Enforcing trauma prevention measures through legislation seems to be the most effective strategy. Educational models have not been adequately evaluated because of methodologic and economic constraints. New prevention initiatives must be supported with more resources and evaluation strategies. Involvement of health care professionals in prevention is encouraged.