Social prescribing practices and learning across the North West Coast region: essential elements and key challenges to implementing effective and sustainable social prescribing services

INTRODUCTION

Social prescribing has become an important feature of the UK primary care offer. However, there remains limited evidence on how best to implement and deliver social prescribing programmes to maximise effectiveness and long-term sustainability.

AIM

To explore social prescribing practices and experience of implementing social prescribing programmes across National Institute for Health and Social Care Research (NIHR) Collaborative Leadership for Applied Health and Care Research (CLAHRC) North West Coast (NWC) and NIHR Applied Research Collaboration (ARC) NWC region to identify key learning points that can be applied to other settings.

METHOD

We held a learning exchange workshop attended by practitioners and Public Advisors who had been involved in implementing and evaluating eight different social prescribing programmes with the support of NIHR CLAHRC NWC. We followed this with an online survey of social prescribing practice and priorities within the NIHR ARC NWC area. We used the findings from the workshop and survey to develop an initial model of the elements needed to successfully implement and sustain a working social prescribing programme.

FINDINGS

We identified three core essential elements for a successful social prescribing programme: a personalised approach; meaningful service-user and community involvement; and whole systems working. These core elements need to be supported with adequate resources in the form of continuity of funding and adequate community resources to refer people to, capacity building and appropriate evaluation.

CONCLUSION

We were able to use a learning exchange workshop to both facilitate learning between practitioners and begin the process of identifying the ingredients needed for a successful social prescribing programme, which may be built on with further research.

Retraction Note: Combined effect of Schroth method and Gensingen brace on Cobb's angle and pulmonary functions in adolescent idiopathic scoliosis: a prospective, single blinded randomized controlled trial

The article "Combined effect of Schroth method and Gensingen brace on Cobb's angle and pulmonary functions in adolescent idiopathic scoliosis: a prospective, single blinded randomized controlled trial", by S.A. Moawd, G. Nambi, A.E. El-Bagalaty, S.M. Hassan, S.E.B. Elsayed, F.M. Aboelmagd, N.A. Alhwoaimel, H.A. Abdeen, published in Eur Rev Med Pharmacol Sci 2023; 27 (2): 601-610-DOI: 10.26355/eurrev_202301_31061-PMID: 36734703 has been retracted by the Editor in Chief for the following reasons: After publication, concerns were raised about the use of copyright and trademark protected terms "Gensingen Brace" and "the Schroth Method" by the authors of the paper without permission for referring to results of a study with treatment of patients with a "Gensingen Brace". The owner of the copyright expressly denies the use of his trademark for scientific statements that are neither authorized by him nor correspond to the product's characteristics and qualities of his well-known products sold under the trademark. After being informed about the copyright and trademark issue, the corresponding author has been acknowledged and affirmed that the authors were not aware of the possible copyright and trademark infringement at the time of submission. The Publisher apologizes for any inconvenience this may cause. https://www.europeanreview.org/article/31061.

Combined effect of Schroth method and Gensingen brace on Cobb's angle and pulmonary functions in adolescent idiopathic scoliosis: a prospective, single blinded randomized controlled trial

OBJECTIVE

To detect the effect of the Schroth method added to the Gensingen brace for six months on Cobb's angle, axial rotation of the trunk, and pulmonary function in adolescent idiopathic scoliosis.

PATIENTS AND METHODS

The study followed a prospective, single-blinded, randomized controlled trial design following the CONSORT guidelines. The study was conducted in Health and Rehabilitation Centre. 42 males aged 10-18 years old, diagnosed with adolescent idiopathic scoliosis (AIS) with curves of 35-40°, were recruited and then were allocated into three groups: Group A, Group B, and Group C.

RESULTS

Significant improvement (p < 0.001) in Cobb's angle and the axial rotation of the trunk (ART) were noted after the treatment in the three groups, while pulmonary function showed better results in Group A (p < 0.001) when compared to the two other groups p ≥ 0.000).

CONCLUSIONS

Six months of Schroth method added to Gensingen Brace demonstrate favorable results in Cobb's angle, thoracic trunk rotation angle, and pulmonary function in adolescent idiopathic scoliosis.

Carvacrol mitigates vancomycin-induced nephrotoxicity via regulation of IkBα/p38MAPK and Keap1/Nrf2 signaling pathways: an experimental study with in silico evidence

OBJECTIVE: Despite its evident renal toxicity, vancomycin is considered an effective glycopeptide antibiotic against life-threatening positive bacterial contagions. The current study aimed to investigate the potential protective effects of carvacrol as well as its underlying mechanism against vancomycin-induced nephrotoxicity. MATERIALS AND METHODS: The animals were randomly classified into four groups (8 rats per group). Group I, which served as a control group, received only vehicles. Group II received a single i.p. injection of 50 mg/kg of carvacrol for seven days. Group III received vancomycin (200 mg/kg, i.p.) as a singular daily dose for seven days. Carvacrol was administered to Group IV seven days prior to the daily vancomycin dose. RESULTS: The results revealed that carvacrol minimized vancomycin-induced renal injury as evidenced by lower serum cystatin C levels and kidney injury molecule-1 (KIM-1), in addition to a decline in renal damage caused by vancomycin as indicated in histopathological assessment. Furthermore, carvacrol significantly attenuated oxidative stress parameters and inflammatory mediators. Moreover, it downregulated Keap1, mitogen-activated protein kinase (p38MAPK), and nuclear factor kappa B (NF-κB) genes and proteins, along with controlling the NF-κB inhibitory protein (IkBα) and nuclear factor erythroid 2-related factor 2 (Nrf2) genes and proteins observed through streaming its genes. A molecular docking technique was also used to investigate the potential interactivity between carvacrol and proteins involved in regulating oxidative injury and inflammatory responses. CONCLUSIONS: The current study findings revealed that carvacrol administration before vancomycin could be a promising therapeutic approach for maceration of renal damage stimulated by vancomycin via controlling IkBα/MAPK and Keap1/Nrf2 signaling molecules.

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Religious practices of Muslim women in the UK during maternity: evidence-based professional practice recommendations

Background

Muslim women commonly observe certain religious practices during their maternity journey and research in this area suggests that more could be done from a service provision perspective to support Muslim women in the UK through this significant life event.

Aim

This study identifies Muslim women’s religious practices during maternity, needs and challenges of religious practice while engaging with maternity services, and support needs from healthcare professionals.

Method

Qualitative mixed method study; that includes eight longitudinal interviews with first-time pregnant Muslim women, five focus groups with 23 Muslim mothers experiencing childbirth in last three years in UK, and 12 one-to-one interviews with Health care Professionals (HCPs) with previous experience working with Minority Ethnic groups. Participants recruited from local Muslim community groups and Maternity Care Provider, North West Coast, England. Data analysed using thematic analysis.

Result

Qualitative findings indicate common religious practices that Muslim women exercise at different stages of their maternity journey. These practices can be divided into two categories of common religious practices for Muslim women that 1) require only healthcare professionals’ awareness of these practices and 2) require awareness and active involvement of healthcare professionals. Findings highlight key recommendations for healthcare professionals when addressing Muslim women’s religious needs in the UK.

Discussion/Conclusion

This study provides evidence-based recommendations for professional practice to assist healthcare professionals in developing understanding and addressing Muslim women’s religious practice needs in the UK. Further research is required to explore the impact of these recommendations for professional practice.

An exploration of young people's, parent/carers', and professionals' experiences of a voluntary sector organisation operating a Youth Information, Advice, and Counselling (YIAC) model in a disadvantaged area

Background

The present evaluation explored young people’s, parents/carers, and healthcare professionals’ perceptions of the Youth Information, Advice and Counselling (YIAC) model operated by a voluntary sector organisation in North West England. With an aim to understand the key components that contribute to enhancing the success of the YIAC model.

Method

Semi-structured interviews and focus groups with young people, parents/carers, and healthcare professionals were conducted. Data were analysed using thematic analysis.

Results

Five main themes were identified from the data: 1) Accessibility and flexibility; 2) Non-clinical model and environment; 3) Staff; 4) Partnership working; and 5) Promotion of positive mental health and wellbeing.

Conclusion

Findings highlight the importance of non-clinical, community-based, ‘one-stop-shop’ hubs for young people in disadvantaged areas. The key components highlighted as facilitating access and engagement include: opportunity to self-refer, choice of location, timely provision of support, non-clinical environment, age appropriate services, a non-hierarchical workforce, inclusive support for family and carers, a focus on wider, often social, issues, and collaboration with partner organisations. These findings suggest that early support hubs for young people’s mental health should have consistent, long-term funding and should exist in every local area.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07800-1.

Distinct effects of trampoline-based stretch-shortening cycle exercises on muscle strength and postural control in children with Down syndrome: a randomized controlled study

OBJECTIVE

The aim of the study was to investigate the effect of a 3-month, trampoline-based stretch-shortening cycle (SSC) exercises on muscle strength and postural control in children with Down's syndrome (DS).

PATIENTS AND METHODS

Thirty-two children with DS aged between 7-9 years were enrolled and randomly assigned into the control group (n = 16); received standard physical therapy (sPT) or SSC group (n = 16); received sPT in addition to a 15-minute, trampoline-based SSC training program twice per week for 12 successive weeks. Lower limb muscle strength and postural stability [anterior/posterior stability index (A/P-SI), medial/lateral stability index (M/L-SI)], and overall stability index (O-SI) were assessed pre- and post-treatment.

RESULTS

Strength of hip extensor (p=0.034) and adductor (p=0.015), knee extensor (p=0.028) and flexor (p=0.01), and ankle dorsi (p=0.033) and plantar flexor (p=0.007) muscles increased significantly in the SSC group when compared with the control group. Also, the A/P-SI (p=0.019), M/L-SI (p=0.002), and O-SI (p=0.021) decreased significantly in the SSC group when compared with the control group, suggesting better postural control.

CONCLUSIONS

Twelve weeks of trampoline-based SSC exercises are likely effective for enhancing muscle strength and postural control in children with DS and should consequently be included in the rehabilitation programs for these children.

Lycopene nanoparticles promotes osteoblastogenesis and inhibits adipogenesis of rat bone marrow mesenchymal stem cells

OBJECTIVE

Lycopene is a carotenoid and antioxidant with potent singlet oxygen quenching ability that reduces oxidative stress and promotes bone health. However, the cellular mechanisms by which lycopene influences bone metabolism are not known.

MATERIALS AND METHODS

The present study investigated the effects of lycopene nanoparticles on the differentiation of rat bone marrow-derived mesenchymal stem cells into osteoblasts or adipocytes.

RESULTS

In osteogenic medium, lycopene supplementation dose-dependently enhanced osteoblast differentiation, as evidenced by the transcription of Alpl, Runx2, Col1a1, Sp7, and Bglap, higher alkaline phosphatase activity, osteocalcin secretion and extracellular matrix mineralisation seen with Alizarin red S staining, and increased haem oxygenase levels. By contrast, lycopene in adipogenic medium inhibited adipocyte differentiation evidenced by decreases in the transcription of Tnfsf11, Tnfrsf11b, Pparg, Lpl, and Fabp4 and reduced fat accumulation observed by Oil Red O staining.

CONCLUSIONS

Lycopene nanoparticles may promote bone health and are considered as a potential candidate for the prevention and/or treatment of bone loss conditions.

The value of involving patients and public in health services research and evaluation: a qualitative study

BACKGROUND

Public and Patient Involvement, Engagement and Participation research encompasses working with patients/service users (people with a medical condition receiving health service treatment), public members, caregivers and communities (who use services or care for patients). The Partner Priority Programme (PPP) was developed by the National Health Service [NHS] and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care [NIHR CLAHRC] NWC to share information and experience on evaluating new services being offered to patients that were seeking to reduce health inequalities, improve people's health and wellbeing and reduce emergency hospital admissions. This paper seeks to explore an approach developed for involving the public as equal partners within the evaluation and decision-making processes of health and social care services research. The aim of this study was to identify how public advisors were included, the impact of their involvement, and how change occurred within the organisations following their involvement.

METHODS

A qualitative approach using focus group discussions was adopted to explore the experiences of two cohorts of participants involved in PPP project teams. Focus groups were held with public advisors (n = 9), interns (n = 9; staff or public who received a funded internship for a PPP project), NHS and Local Authority initiative leads (n = 10), and academic facilitators (n = 14). These were transcribed verbatim and analysed using a thematic approach.

RESULTS

Thirty-two public advisors were recruited to support 25 PPP projects across the Collaboration for Leadership in Applied Health Research and CLAHRC North West Coast [NWC] partner organisations. Three inter-related themes were conceptualised: 1)"Where it all started - involving public advisors" identified the varying journeys to recruitment and experiences of becoming a public advisor; 2)"Steps toward active involvement and engagement" related to public advisors becoming core team members; and 3) "Collaborative working to enhance public and patient involvement" relayed how projects identified the benefits of working jointly with the public advisors, particularly for those who had not experienced this style of working before.

CONCLUSIONS

The findings indicate that the PPP model is effective for embedding Public and Patient Involvement [PPI] within health services research, and recommends that PPI is integrated at the earliest opportunity within research projects and service evaluations through the use of support-led and facilitative programmes.

The impact of COVID-19 social distancing and isolation recommendations for Muslim communities in North West England

INTRODUCTION

People from Minority Ethnic backgrounds living in the UK are at greater risk of not only contracting COVID-19, but also experiencing serious consequences of the virus. These emerging health inequalities mirror those already evident in UK society.

AIM

The aim of this study was to understand how COVID-19 and the associated imposed restrictions affected the lives of people from the Muslim community living in the North West of England.

METHOD

Twenty-five in-depth qualitative interviews and four focus groups (n = 22) explored individual experiences of COVID-19 and imposed restrictions. Data were analysed thematically.

FINDINGS

The virus and associated imposed restrictions had negative impacts on the psychological wellbeing of participants, their families and the wider community. Worry and low mood were particular features of participant's pandemic stories. Main concerns were those of contracting and transmitting the virus to others and employment-related difficulties. Low mood was particularly linked to the impact of restrictions on fundamental interactions embedded within cultural and religious practices. These practices are central to feelings of belonging and connectedness within the Muslim community. Religious beliefs were important in helping to mitigate psychological distress for some participants.

CONCLUSION

Psychological distress was associated with COVID-19 virus and impact of COVID-19 restrictions on livelihoods and fundamental human interactions. Better provision of culturally appropriate information, improving local channels of communication and practical support are important during times of pandemic when usual support systems may be disrupted.

How do Muslim community members perceive Covid-19 risk reduction recommendations - a UK qualitative study?

Introduction

The evidence is now unequivocal that people from Black and Minority Ethnic Backgrounds (BAME) living in the UK are disproportionately affected by covid-19. There is growing evidence that the reasons for this difference are multi-factorial and need further exploration.

Aim

The aim of this study was to understand better, perceptions of risk and responses to covid-19 of members of the Muslim community living in the North West of England, and to understand the facilitators and barriers to adherence to restrictions and guidance measures.

Method

A total of 47 participants took part in 25 in-depth qualitative interviews and four focus groups (n=22) that explored perceptions of risk and responses to risk from covid-19. Data were analysed thematically.

Findings

Participants were aware of the mechanism of transmission of covid-19 and took steps to mitigate risk of transmission including, observing a range of hygiene practices and following social distancing guidance. Increased risk of covid-19 for BAME populations was explained largely in terms of exposure to the virus due to the types of employment people from BAME populations are employed in. Limitations both within the working environment and more generally in public spaces, was identified as problematic for effective social distancing. The closure of mosques sent out a strong message about the seriousness of the virus and religious teachings reinforced hygiene and social distancing guidelines.

Conclusion

Across society there are people that adhere to restrictions and guidelines and those that do not. Improving local information provision and communication pathways during times of the pandemic, could aid understanding of risk and promote adherence to social distancing restrictions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10506-4.

Prevalence of ticks (Acari: Ixodidae) and Theileria annulata infection of cattle in Gezira State, Sudan

This study was conducted in Gezira State, central Sudan during January, May and August 2014 to determine species of ticks infesting cattle and prevalence of Theileria annulata infection and antibodies. A total of 200 head of cattle were sampled for ticks, blood smears, lymph node biopsy smears and sera from five study areas. Zebu (Butana and Kenana) and cross-bred (Zebu X Friesian) cattle of both sexes were sampled. Cattle age groups were younger than one year, one year to younger than four years and four years and older. Coat colour of cattle was recorded. The results revealed that cattle were infested with Rhipicephalus evertsi evertsi (n = 562, 51.6%), Hyalomma anatolicum (n = 289, 26.5%), H. rufipes (n = 70, 6.4%), R. sanguineus sanguineus (n = 59, 5.4%), R. decoloratus (n = 39, 3.6%), Amblyomma lepidum (n = 35, 3.2%), H. impeltatum (n = 26, 2.4%) and H. dromedarii (n = 9, 0.8%). Out of 200 blood and biopsy smears, 33 (16.5%) showed piroplasms for Theileria spp., while 29 (14.5%) were positive for Theileria spp. schizonts. Seropositivity for T. annulata using indirect fluorescent antibody (IFA) test was 94 (47%). It is concluded that there are three genera of hard ticks and eight species in Gezira State and tropical theileriosis is endemic in the state. These findings are the first records in Gezira State, Central Sudan and it is highly recommended to consider the endemicity of tropical theileriosis particularly in cattle upgrading programmes.

Muslim women's experiences of maternity services in the UK: qualitative systematic review and thematic synthesis

BACKGROUND

This review aimed to identify and synthesise evidence of Muslim women's experiences of maternity services in the UK. A systematic review and thematic synthesis of qualitative evidence, unrestricted by type of publication was conducted. Muslim women who had accessed maternity services in the UK, regardless of obstetric or medical history were included.

METHOD

Databases were searched from 2001 to 2019 and screened for inclusion using pre-determined criteria. The Critical Appraisal Skills Programme Qualitative Research Checklist was used to assess study quality and findings were synthesised using thematic synthesis, as described by Thomas and Harden.

RESULTS

Six studies were included. The following five themes were identified: Islamic practices and Individualised care; Talk, Teach and Translate; Injustice, Inequity and Intolerance; If Allah wills; and, 'It's not all that bad'. Synthesis highlighted the significance of Islam in shaping many of the women's decision-making relating to antenatal screening and medication, which was contrasted with healthcare professionals' limited awareness of the importance of Islam for motherhood. The majority of women experienced poor maternity care which at times indicated stereotypical and discriminatory behaviour.

CONCLUSIONS

Education for healthcare professionals is warranted, to enhance the quality and cultural competency in providing appropriate care that acknowledges and meets Muslim women's needs.

Social prescribing for people with mental health needs living in disadvantaged communities: the Life Rooms model

BACKGROUND

People live socially complex lives and have different health care needs influenced by socio-economic factors such as deprivation, unemployment, and poor housing. Lack of access to community based social care results in people seeking social support from health care services. This study explores the Life Rooms as a social prescribing model addressing the social determinants of mental health by providing support and access to resources in a local community setting. With an aim to identify key elements that contribute toward enhancing the effectiveness of the Life Rooms social prescribing approach.

METHODS

Data were obtained through six semi-structured focus groups with mental health service users from two locations in the North West of the UK. Postcode data was collected to generate an Index for Multiple Deprivation (IMD) score, to understand their socio-economic background. Data were analysed using thematic analysis.

RESULTS

A total of 18 participants took part in the study. The majority of participants came from disadvantaged backgrounds; 14 participants measuring 3 and below in terms of overall IMD scores and 9 participants belonged to the poorest decile (IMD score = 1). Participants reported on different elements of the Life Rooms which they found as an effective approach to care. Four main themes emerged from the data: 1) social belonging: being able to just 'be' 2) resourceful and accessible; 3) social inclusion and connectedness; and 4) moving forward: self-development and independence.

CONCLUSION

Findings support the need and benefit social prescribing to improve mental health wellbeing and reduce the burden of mental illness.

Assessment of the prevalence of Theileria lestoquardi in sheep from the Sudan using serological and molecular methods

Malignant theileriosis of sheep and goats caused by Theileria lestoquardi is considered to be among the most important tick borne diseases in the Sudan. Information on the prevalence of the disease in different parts of the Sudan is limited. The purpose of this study was to estimate the prevalence of the disease in five states of the Sudan using molecular and serological assays. A total of 393 blood and serum samples from clinically asymptomatic sheep were analysed using nested reverse line blot (nRLB) and loop mediated isothermal amplification (LAMP), as well as an enzyme-linked immunosorbent assay (ELISA). The results indicated a sero-prevalence of 33.8% while RLB and LAMP assays revealed molecular prevalences of 29.5 and 22.6% respectively. The prevalence of Theileria lestoquardi varied significantly according to the geographical origin of the infected animals, whereas age and gender did not have a significant effect. RLB data indicated that T. lestoquardi usually occurred as a co-infection with the non-pathogenic Theileria ovis. Using RLB as a gold standard, a sensitivity of 68.1% and a specificity of 96.4% were recorded for LAMP and a sensitivity of 75.9% and a specificity of 83.8% for ELISA. The Kappa coefficient between nRLB and LAMP indicated a significant level of agreement (0.692), but only moderate concordance (0.572) between nRLB and ELISA. The results of the present study confirm and extend earlier findings regarding the widespread of T. lestoquardi infections in sheep in the Sudan. The data provide evidence that should enable the veterinary authorities to deploy appropriate control measures.

Molecular, serological and parasitological survey of Theileria annulata in North Kordofan State, Sudan

This survey was conducted to detect Theileria annulata infection in indigenous (Zebu) and cross (indigenous × Friesian) cattle (n 604) of different sex & age groups, and to investigate prevalence of ticks infesting cattle in North Kordofan State, Sudan. Ticks, blood smears, serum samples and blood spots on filter paper were collected from four municipalities at four monthly intervals during the period from August 2008 to July 2009. Out of 604 blood smears, 69 (11.4%, 95% CI: 16.9-5.9) were positive for Theileria piroplasms; whereas, out of 240 serum samples, 164 (68.3%, 95% CI: 89.3-47.3) were positive for antibodies against T. annulata using IFA test. Using PCR, out of 100 blood spots on filter paper, 8 (8%, 95% CI: 9.6-6.4) revealed T. annulata DNA. The highest prevalence of Theileria spp. piroplasms and T. annulata antibodies was recorded in August (15.9 ± 4.6) followed by February (13.3 ± 3.8) and the lowest was in May (3.9 ± 1.0). Among cattle breeds, the highest prevalence of piroplasms (11.9 ± 5.0) and T. annulata antibodies (68.9 ± 10) was among zebu cattle. PCR assays revealed the highest prevalence rate of T. annulata DNA in February (12.5 ± 1.4) followed by August (6.1 ± 0.7) and the lowest was in May (5.7 ± 0.7). According to cattle breeds, T. annulata DNA was detected in cross-bred cattle (3.3 ± 0.4) more than zebu cattle (10 ± 1.6). Seven tick species belonging to four genera and were identified, Amblyomma lepidum, Hyalomma dromedarii, H. impeltatum, H. rufipes, Rhipicephalus evertsi evertsi, Rhipicephalus decoloratus, R. annulatus. The most abundant tick species was H. rufipes followed by H. impeltatum, R. e. evertsi, H. dromedarii, R. decoloratus, A. lepidum and R. annulatus. Theileria annulata has been detected for the first time in North Kordofan State, though at a low prevalence rate. This finding is an alarming situation since tropical theileriosis is an emerging disease and it is widely believed that this economically important tick-borne parasite does not exist in this state. The possible alternative vector(s) of T. annulata in the absence of the known vector H. anatolicum is discussed.

Aflatoxin, proximate composition and mineral profile of stored broiler feed treated with medicinal plant leaves

OBJECTIVES

In the present investigation, the Morus alba (M. alba), Vitis vinifera (V. vinifera), Ficus religiosa (F. religiosa) and Citrus paradisi (C. paradisi) leaves anti-aflatoxigenic activities were evaluated in Aspergillus flavus (A. flavus) inoculated feed.

METHODS

The broiler feed inoculated with A. flavus was treated with selected medicinal plant leaf powder (5%, 10% and 15% w/w) and stored for the period of six months at 28°C and 16% moisture. The aflatoxins (AFTs) were estimated at the end of each month by Reversed Phase High Performance Liquid Chromatography (RP-HPLC) method along with proximate composition and mineral contents.

RESULTS

Plant leaves controlled AFTs efficiently without affecting the feed proximate composition and mineral contents. The M. alba leaves completely inhibition (100%) the AFTs (B₁ and B₂) in feed at very low concentration (5%). Other plants also showed significant (P<0.05) inhibition of AFTs production without affecting the feed quality over the storage period of six months.

CONCLUSION

Based on promising efficiency of selected medicinal plant leaves, A. flavus produced AFTs could possibly be controlled in stored poultry feed.

Note: A novel trigger generator for a pseudospark switch

A novel trigger generator for operating a pseudospark switch has been developed based on a series connection of several insulated gate bipolar transistors. The trigger generator can be operated in single shot mode up to a repetition rate of 1 kHz. It is characterized by a fast rise time and low jitter between the output trigger pulses of less than 1 ns. It produces 3 kV, 1 μs pulses into a 50 Ω load that can trigger a pseudospark switch. By eliminating bulkier, slower high voltage components, the overall volume of the trigger generator is reduced. This allows for faster, high voltage switching to take place and thereby increasing the power density of the unit. Using this pseudospark trigger generator, it is possible to trigger single or multiple pseudospark gaps without the requirement to use a pulse shaping circuit.

Metarhizium anisopliae as a biological control agent against Hyalomma anatolicum (Acari: Ixodidae)

In the Sudan, ticks and Tick-borne Diseases (TBDs) with subsequent costs of control and treatment are causing substantial economic loss. Control of ticks is mainly by chemical insecticides. The rising environmental hazards and problem of resistance has motivated research on biological agents as alternative methods of control. The present study aims at controlling livestock ticks using fungi for their unique mode of action besides their ability to adhere to the cuticle, to germinate and penetrate enzymatically. The study was conducted to evaluate the fungus Metarhizium anisopliae for tick control as an alternative mean to chemical acaricides. Pathogenicity of the fungus was tested on different developmental stages of the tick Hyalomma anatolicum. The fungus induced high mortality to flat immature stages. It, also, affected reproductive potential of the females. Egg laid, hatching percent, fertility and moulting percent of immature stages were significantly (p < or = 0.05) reduced. It was, also, shown that the fungus had ability to adhere to the cuticle and penetrate the integument of the tick. Conidia of the fungus were isolated from their internal tissues. This phenomenon is important in considering fungi as bioinsecticides. Infection of eggs laid by treated engorged female ticks, with the fungus might demonstrate suggesting transovarian transmission. The use of M. anisopliae to control ticks is discussed.

Experience of fibrosing cholestatic hepatitis with hepatitis C virus in kidney transplant recipients

BACKGROUND

Fibrosing cholestatic hepatitis C (FCH-C) is a rare entity that occurs among immune-compromised patients resulting from the direct hepatotoxicity of a high intracellular viral load along with an ineffective immune system ultimately leading to a fatal outcome. We have describes herein 4 renal transplant recipients who were diagnosed with FCH-C at our institution in the last 8 months.

METHODS

Four renal transplant recipients presented with jaundice and deteriorating liver function tests. They were diagnosed to display FCH-C based on the presence of hepatitis C virus (HCV) RNA and characteristic liver biopsy findings; there was no evidence of any other cause of cholestasis or biliary obstruction.

RESULTS

The patients were men of ages 40, 25, 20, and 27 years. The durations after transplantation were 1.5, 10, 1.5 and 2.0 years, respectively. In all cases pretransplantation screening was negative for HCV antibody, HCV RNA, and hepatitis B surface antigen (HBsAg). All 4 patients were infected with genotype 1, whereas case 2 had coinfection with type 3. Cases 1 and 2 who were treated with interferon and ribavirin, showed improvement in cholestasis but did not achieve a rapid virological response. Case 1 developed graft dysfunction secondary to acute cellular rejection at 4 months after initiation of interferon treatment, which was treated with pulse steroids. Interferon-based therapy was stopped prematurely in both cases due to pancytopenia. Case 3 developed florid pyelonephritis and died without receiving therapy for hepatitis C. Case 4 was managed conservatively by decreasing the immunosuppression with regular monitoring.

CONCLUSION

FCH-C is difficult to treat and shows high morbidity and mortality rates. Treatment is associated with a risk of graft rejection.

Rayleigh-Taylor instability of an ultrathin foil accelerated by the radiation pressure of an intense laser

We report experimental evidence for a Rayleigh-Taylor-like instability driven by radiation pressure of an ultraintense (10(21) W/cm(2)) laser pulse. The instability is witnessed by the highly modulated profile of the accelerated proton beam produced when the laser irradiates a 5 nm diamondlike carbon (90% C, 10% H) target. Clear anticorrelation between bubblelike modulations of the proton beam and transmitted laser profile further demonstrate the role of the radiation pressure in modulating the foil. Measurements of the modulation wavelength, and of the acceleration from Doppler-broadening of back-reflected light, agree quantitatively with particle-in-cell simulations performed for our experimental parameters and which confirm the existence of this instability.

Excitation wavelength dependence of water-window line emissions from boron-nitride laser-produced plasmas

We investigated the effects of laser excitation wavelength on water-window emission lines of laser-produced boron-nitride plasmas. Plasmas are produced by focusing 1064 nm and harmonically generated 532 and 266 nm radiation from a Nd:YAG laser on BN target in vacuum. Soft x-ray emission lines in the water-window region are recorded using a grazing-incidence spectrograph. Filtered photodiodes are used to obtain complementary data for water-window emission intensity and angular dependence. Spectral emission intensity changes in nitrogen Ly-α and He-α are used to show how laser wavelength affects emission. Our results show that the relative intensity of spectral lines is laser wavelength dependent, with the ratio of Ly-α to He-α emission intensity decreasing as laser wavelength is shortened. Filtered photodiode measurements of angular dependence showed that 266 and 532 nm laser wavelengths produce uniform emission.

Ticks (Acari: Ixodidae) infesting camels (Camelus dromedarius) in Northern Sudan

Monthly total body tick collections from 13-20 camels were conducted for 2 consecutive years (2000-2001) in Northern Sudan. Tick populations were correlated with locality, season, predeliction site, sex and coat colour. Hyalomma dromedarii was found to be the predominant (89%) tick species infesting the camels. Other tick species found in very low numbers were Hyalomma impeltatum (7.7%), Hyalomma anatolicum anatolicum (3.3%), Hyalomma truncatum (0.29%), Hyalomma marginatum rufipes (0.25%), Rhipicephalus praetextatus (0.30%) and Rhipicephalus sanguineus group (0.09%). Nymphs of the genus Hyalomma were collected in significant numbers. Adult ticks significantly preferred to attach to the lower parts of the camel's body for feeding while the nymphs preferred the back of the animal. Female camels harboured more ticks than males while higher infestations were recorded on camels with a grey coat colour compared to those with a brown coat colour. Ticks were found on camels throughout the year and increased in numbers during March to October with a peak in September.

Development of the immature stages of Amblyomma lepidum (Acari: Ixodidae) under field conditions

According to this study, the effect of seasonality on the development of larvae and nymphs of Amblyomma lepidum was highly significant (P< or =0.001). The moulting of larvae was only possible in the rainy season, where means of 76.8 and 73.1% were recorded in the first and the second year, respectively. Nymphs, in the same period, achieved 68.8 and 71.8% moult. In winter, only 11.8 and 12.2% of nymphs succeeded to moult in the first and the second year, respectively. Males outnumbered females, but the effect of seasonality on the male/female ratio was statistically insignificant. The development of both stages in summer was unsuccessful.

Systematics of early and middle Miocene Old World monkeys

New information about the early cercopithecoids Prohylobates tandyi (Wadi Moghra, Egypt) and Prohylobates sp. indet. (Buluk and Nabwal, Kenya) is presented. Comparisons are made among all major collections of Early and Middle Miocene catarrhine monkeys, and a systematic revision of the early Old World monkeys is provided. Previous work involving the systematics of early Old World monkeys (Victoriapithecidae; Cercopithecoidea) has been hampered by a number of factors, including the poor preservation of Prohylobates material from North Africa and lack of comparable anatomical parts across collections. However, it is now shown that basal cercopithecoid species from both northern and eastern Africa can be distinguished from one another on the basis of degree of lower molar bilophodonty, relative lower molar size, occlusal details, symphyseal construction, and mandibular shape. Results of particular interest include: 1) the first identification of features that unambiguously define Prohylobates relative to Victoriapithecus; 2) confirmation that P. tandyi is incompletely bilophodont; and 3) recognition of additional victoriapithecid species.

High repetition rate pseudospark trigger generator

We report the design and development of a high repetition rate pseudospark trigger generator for operating pseudospark switches with a low impedance of approximately 50 Omega between the trigger pins. The trigger generator can be operated from a single-shot mode up to a repetition rate of 1 kHz. It produces 3 kV, 1 mus pulses into a 100 Omega load to trigger a single pseudospark gap. Also, with the addition of a self-break spark gap and pulse forming network, the trigger generator can be used to trigger a pseudospark gap with low jitter. In this configuration, it produces 300 ns, 3 kV pulses with rise time of 10 ns. The jitter between trigger pulses applied to the pseudospark is less than 1 ns.

Reliminary survey of ticks (Acari: Ixodidae) on cattle in Central Equatoria State, Southern Sudan

In a preliminary survey conducted in 2005, the species composition and seasonality of ticks infesting cattle in Central Equatoria State, Southern Sudan was determined. Three locations were selected (Gumbo, Khor Rumla and Nyaing) and surveyed every 3 months. Two cattle herds in each of the three locations were visited four times during the study period. Total body collections of ticks were made from each of five cattle (Nilotic Zebu breed) kept in six different herds. Four tick genera and ten species were identified. The tick species identified were Amblyomma lepidum, Amblyomma variegatum, Boophilus annulatus, Boophilus decoloratus, Hyalomma marginatum rufipes, Hyalomma truncatum, Rhipicephalus appendiculatus, Rhipicephalus evertsi evertsi, Rhipicephalus praetextatus and Rhipicephalus sanguineus group. The highest number of ticks was collected in October during the rainy season. A finding of great significance was that R. appendiculatus, vector of East Coast fever, has now firmly established itself throughout the year with possible implications for cattle production in Central Equatoria State.

Comparisons among two serological tests and microscopic examination for the detection of Theileria annulata in cattle in northern Sudan

We tested the agreement between microscopic examination (ME), a surface protein-detecting enzyme-linked immunosorbent assay (TaSP ELISA) and an indirect fluorescent assay (IFA) for detection of Theileria annulata in 2,661 naturally infected cattle from northern Sudan (samples collected between June 2001 and July 2002). In the ME, we detected piroplasms in 364/2,661 cattle (14%), and the kappas between the ME and the serological tests were poor (TaSP ELISA 10%; IFA 8%). The TaSP ELISA detected 885/2,661 cattle as positive, and the Rogan-and-Gladen corrected true prevalence of this sample was estimated to be 30%. The relative sensitivity and specificity of the IFA (compared to the previously validated TaSP ELISA) were 70.7% and 81.8%, respectively.

Visceral leishmaniasis and tuberculosis in patients with HIV co-infection

We describe here two cases, one male and one female, both age 40 years, with visceral leishmaniasis and HIV-1 co-infection. The female patient had features of Koch's abdomen. The male patient had features of tuberculous lymphadenitis and bilateral pleural effusion more marked on the right side. Both were treated with highly active antiretroviral therapy, antituberculous drugs, antibiotics, antifungal medicine (fluconazole) and miltefosine. Both patients showed marked improvement with therapy.

Natural infection rates and transmission of Theileria annulata by Hyalomma anatolicum anatolicum ticks in the Sudan

Hyalomma anatolicum anatolicum nymphs were collected from two localities in the Sudan: Eddamer in Northern Sudan and Wad-Medani in Central Sudan. They were allowed to moult to adult ticks, which were assessed for Theileria infection in their salivary glands using Feulgen stain. At Eddamer, 49.6% of 123 ticks examined were infected with Theileria and the mean intensity of infection was 1.3 (i.e. the number of infected acini/number of infected ticks). At Wad-Medani, 8.6% of 162 ticks were infected and the mean intensity of infection was 7.9. The prevalence of infection was higher in female than in male ticks at both localities. When adult H. a. anatolicum were applied onto two susceptible calves, both animals developed the severe form of theileriosis.

Egg storage period and weight effects on hatchability of ostrich (Struthio camelus) eggs

We studied the affects of storage period and egg weight on the hatchability of 314 ostrich (Struthio camelus) eggs. Eggs were stored at 20 degrees C and 65% RH before incubation at the Poultry Research, Teaching and Extension Center at Texas A&M University (College Station, TX). Eggs were classed by storage period (< or = 5, > 5 < or = 10, > 10 < or = 15, or > 15 < 24 d) and egg weight (< or = 1,450, > 1,450 < or = 1,650, or > 1,650 g) to determine the influence of storage period and egg weight on hatchability, egg weight loss, incubation period, and absolute and relative chick weights. Eggs were incubated at 36.5 to 37.0 degrees C and 25% RH through 38 d of incubation and 36 degrees C and 30% RH thereafter. Mean egg weight loss was greater from eggs of the longest storage period group (> 15 < 24 d) at 21 or 38 d when compared with eggs of the shorter storage periods, but there were no differences at 7, 14, or 28 d among all storage period groups. Mean hatchability was higher in eggs stored < or = 10 d than eggs stored > 15 < 24 d, but hatchability of eggs stored >10 < or = 15 d was not different from eggs stored < or = 10 d or > 15 < 24 d. Incubation period was longer, and absolute and relative weights were higher in eggs stored >15 d than was observed in eggs stored < or = 15 d. Negative correlations were detected between egg weight and moisture loss at 38 d (-0.55) and between hatch time and moisture loss (-0.25). Hatchability was higher in small eggs than medium eggs (< or = 1,650 g). A positive correlation was observed between chick and egg weights (0.84). The results indicated that storage period and egg weight affected egg weight loss. Our results suggested that the most effective storage period was less than 15 d to maintain hatchability for ostrich eggs when incubated at 36.5 to 37.0 degrees C with 25% RH.

Preliminary survey of ticks (Acari: Ixodidae) on cattle in northern Sudan

In a cross sectional survey conducted during the period June 2001 to July 2002, the geographical distribution of ticks on cattle in the Sudan was determined. Seventeen locations were surveyed from Northern, Central, Eastern, Western, Blue Nile and White Nile Provinces. Total body collections of ticks were made from 20 cattle at each location. Four tick genera and 11 species were identified. The tick species collected included Amblyomma lepidum, Amblyomma variegatum, Boophilus decoloratus, Hyalomma anatolicum anatolicum, Hyalomma dromedarii, Hyalomma impeltatum, Hyalomma marginatum rufipes, Hyalomma truncatum, Rhipicephalus evertsi evertsi, Rhipicephalus sanguineus group and Rhipicephalus simus simus. Major ecological changes have occurred due to extensive animal movement, deforestation, desertification and establishment of large mechanized agricultural schemes. These factors have certainly affected the distribution of ticks and tick-borne diseases in the Sudan. The absence of A. variegatum and A. lepidum in northern Sudan was not surprising, since these tick species are known to survive in humid areas and not in the desert and semi-desert areas of northern Sudan. The absence of B. annulatus in northern and central Sudan is in accordance with the finding that this tick species is restricted to the southern parts of the central Sudan. The presence of H. anatolicum anatolicum in Um Benin in relatively high abundance is an interesting finding. The present finding may indicate that the southern limit of this species has changed and moved southwards to latitude 13 degrees N. It is concluded that major changes in tick distribution have taken place in the Sudan.

Incubation Temperature for Ostrich (Struthio camelus) Eggs

The impact of incubation temperature on egg weight loss, embryonic mortality, incubation period, hatchability, and chick weight in 394 ostrich (Struthio camelus) eggs was studied. Eggs were obtained from 3 farms in Texas. Three incubation temperatures (36.5, 37.0, or 37.5 degrees C) with relative humidity ranging from 20 to 30% were used. Results showed that incubation of fertile eggs at 36.5 degrees C increased hatchability and incubation period in comparison with other treatments. The incidence of dead in shell and total dead embryos was increased at 37.5 degrees C when compared with 36.5 degrees C. No differences in hatchability, incubation period, dead-in-shell embryos, and total dead embryos were observed between eggs incubated at 37.0 or 37.5 degrees C. Neither chick weight nor egg weight loss at 7, 14, 28, or 38 d of incubation was affected by incubation temperature, but egg weight loss at 21 d was lower for eggs incubated at 37.5 degrees C than for the other treatments. Results show that the most effective incubation temperature for the ostrich is lower than the most effective incubation temperature for most bird species.

Effect of acetyl salicylic acid in drinking water on reproductive performance of Japanese quail (Coturnix coturnix japonica)

The impact of acetyl salicylic add (ASA) on reproductive performance during periods of heat stress was studied in Japanese quail (Coturnix coturnix japonica). During a season when daily high temperatures averaged between 34 and 40 degrees C, four treatments each containing four replicates of five males and five females were given 0, 0.5, 1.0, or 1.5 g/L ASA in drinking water from 34 to 45 wk of age. At 39 wk of age control quail were lighter than quail fed ASA. Quail receiving 1.5 g/L ASA exhibited increased fertility, hatchability, and egg production and decreased late dead and total embryonic mortality. Early dead embryos, pips, chick weight, and egg weight were not different among treatments. The lumen of uterovaginal junction sperm host glands (UVJSHG) from control quail was apparently devoid of spermatozoa, whereas quail receiving 1.5 g/L ASA had the greatest apparent accumulation of spermatozoa. Control caudal infundibulum host glands (CPOI) were devoid of spermatozoa in contrast with CPOI from quail receiving ASA. Results show that UVJSHG lumens from quail receiving 1.5 g/L ASA had larger inside diameters than other treatment groups. However, the CPOI inside diameter and the outside diameters of both UVJSHG and CPOI were not affected by ASA. Adding 1.5 g/L ASA to the drinking water of quail under heat stress improved body weight, fertility, hatchability, embryonic mortality, egg production, egg specific gravity, and sperm storage capacity.

Effect of feeding time on the reproductive performance of Japanese quail (Coturnix coturnix japonica)

Several feeding regimens are applied to improve performance of fertile egg production during times of heat stress. During a period of heat stress (34 to 36 degrees C), two feeding periods were used to measure the impact of feeding time on reproductive performance of Japanese quail (Coturnix cotunix japonica) between 44 and 60 wk of age. Each feeding time treatment had 25 individually caged male and female pairs. Quail were fed ad libitum between 0600 to 1400 or 1400 to 2200 h daily. Results indicated that feeding between 0600 to 1400 h reduced BW, fertility, hatchability, egg production, and egg specific gravity when compared with the effects of feeding between 1400 to 2200 h. Feeding time had no effect on total embryonic mortality, egg weight, or the period between subsequent ovipositions. The different feeding times affected the distribution curve of oviposition over time. An instrument designed to record oviposition time is described. Results showed that selection of the time of day for application of an 8-h restricted feeding regimen affected BW, fertility, hatchability, egg production, egg specific gravity, and oviposition time in Japanese quail.

Effect of early feed restriction on reproductive performance in Japanese quail (Coturnix coturnix japonica)

Reproductive performance of quail (Coturnix coturnix japonica) was evaluated following feed restriction (100, 85, and 70% of ad libitum) between 2 to 5 wk of age with three replicates of 12, 2-wk-old chicks per replicate. Body weight, feed conversion, and leucocyte distribution were measured during feed restriction. After experimental feed treatment, BW, age at first egg, egg production, fertility, hatchability, and embryonic mortality were evaluated from five replicates of two females and one male per treatment. Feed-restricted female chicks had lower BW from 3 to 5 wk of age, but male weights were depressed only during the most severe restriction at 4 and 5 wk. No treatment differences were observed among BW within a sex from 6 to 13 wk. Body weights at first egg were significantly heavier for females fed 70% ad libitum than for birds on other treatments. Fertility, age at first egg, feed conversion, egg production, and egg weight were unaffected by feed restriction. Although hatchability was unaffected by feed restriction, percentage of late dead and total dead embryos were significantly reduced in eggs from restricted quail. Thirty quail fed 70% of ad libitum control intake had significantly increased egg specific gravity. Feed restriction increased the percentage of heterophils and basophils and the heterophil/lymphocyte ratio, whereas the percentage of lymphocytes and eosinophils decreased. Feed can be restricted to 85 or 70% of ad libitum feed intake from 2 to 5 wk of age without detrimentally affecting reproductive parameters between 6 to 13 wk of age.

Monitoring of cadmium in "on" and "off" date palms

The study demonstrated that the mature dates we investigated were considered safe for human consumption. However, our findings revealed that much of the early fruit and leaves, which appeared at the advent of the fruiting season, possessed elevated levels of cadmium (Cd) that could accumulate in the food chain and thus impact adversely on the environment. In addition, animal feed for livestock contains date leaves, which should be restricted to the mature ones. The monitoring of cadmium in date palms is of considerable interest to environmental science and the thrust of this work, therefore, involved measurement, by ICP, of Cd in dates and corresponding leaf specimens, and evaluation of its distribution during the developmental stages of the fruiting season. Thirty-six date samples and 36 leaf specimens of the Fard cultivar were collected from "on" and "off" date palms during the Kimri, Bisir and Rutab stages of the fruiting season and subjected to suitable digestion procedures. Sample masses of typically 1 g (dry weight) were prepared in 25 ml dilute acid solution and investigated for trace levels of Cd by ICP-AES. Special attention was paid to contamination and the validation of our methodology. The Cd "threshold" in our study was 50 ng/g, in keeping with the levels of tolerance appearing in the literature. For the dates we found elevated levels of Cd [> 50 ng/g] in most of the samples, for both categories of "on" and "off" trees, during the Kimri stage. In the case of the leaves, the "on" samples revealed significant values up to 125 ng/g in Bisir, in some cases, but the trend for the "off" trees remained the same with the highest levels [> 100 ng/g] recorded during Kimri. Safe levels were attained during Rutab for all specimens. The possibility of a connection between Cd toxicity and the alternate-bearing phenomenon is discussed and this could be the subject of future interest.

Reduction of halogenated hydrocarbons in aqueous media: I. Involvement of sulfur in iron catalysis

Experiments were carried out to investigate the reduction of tri- and tetra-chloroethene with iron in aqueous solutions. Results indicate (i) dependence of the dehalogenation capacity of the iron on its sulfur content and (ii) that ethyne was the primary dehalogenated hydrocarbon for both compounds. A reaction mechanism based on in situ formation of ferrous sulfide as the catalyst and its reaction with the halocompounds in the presence of hydrogen has been postulated.

Effect of case managers with a general medical patient population

The objectives of this study were to evaluate the effect of inpatient case management (CM) on a general medical service and to determine if a prediction rule, identifying patients likely to need discharge planning services, could define a subset of patients for whom CM would be most effective. We hypothesized that CM would have greatest impact on patients predicted to be at highest risk of needing discharge planning to arrange for post-discharge medical services. We carried out a prospective controlled study. Six general medicine teams from a 600-bed urban teaching hospital were randomly assigned to CM (n = 4) or standard care (SC) (n = 2). Number of patients = 302 (207 CM; 95 SC). Case managers participated in daily physician team rounds and coordinated discharge planning for CM patients; SC patients received discharge planning from staff nurses or discharge planners when requested by physicians. The outcomes measured were deviation from the hospital length of stay (LOS) expected for a patient's diagnosis, patient satisfaction and non-acute medical service utilization during the month after discharge. Overall, patients from CM and SC teams did not differ in their deviation from expected LOS, post-discharge medical service utilization and patient satisfaction. However, after stratifying patients by their predicted need for post-discharge medical services, only patients in the 'high risk' category had a significantly shorter LOS under CM (2.9 days shorter than SC patients; P = 0.02). We concluded that, in this study, the effect of case managers on a general medical service was limited to shortening LOS only among a stratum of high risk patients.

Amphotericin B deoxycholate treatment of visceral leishmaniasis with newer modes of administration and precautions: a study of 938 cases

Out of 938 parasitologically confirmed patients with visceral leishmaniasis treated with amphotericin B (1 mg/kg bodyweight daily infused in 2 h for 20 days), 935 were cured clinically, 933 parasitologically and 931 ultimately (no relapse within 6 months). Two parasitologically 'not cured' and 4 relapsed patients were cured with 25 infusions, and 1 with double relapse with 30 infusions. The treatment was started only when serum haemoglobin reached 5 g/dL, serum electrolyte imbalance was corrected and sodium stibogluconate-induced myocardial damage stabilized after 10 days' rest. Bronchopneumonia, cardiac failure and acute renal failure caused the death of 1 patient each. Nightblindness, angular stomatitis, neuritis, and petechial haemorrhages improved with appropriate treatment; 2 patients were given blood transfusion for post-treatment anaemia. Nausea and anorexia, and changes in serum creatinine and potassium, became normal in 2 weeks. Immediate withdrawal of the drug and restart after 10 days cured 2 patients who developed acute renal failure. Infusion-related toxicities--shivering, rigor and fever--were minimized but not eliminated by prior administration of hydrocortisone. Tuberculosis and visceral leishmaniasis were treated concurrently. Four pregnant patients were successfully treated without harmful effects on mother and child. It was concluded that the dosage of amphotericin B used was an effective and well-tolerated regimen and achieved 99% cure. Toxicity could be minimized with some precautions. All unresponsive and relapsed patients responded to more amphotericin and no resistance to the drug was seen.

Do the diminishing efficacy and increasing toxicity of sodium stibogluconate in the treatment of visceral leishmaniasis in Bihar, India, justify its continued use as a first-line drug? An observational study of 80 cases

Eighty parasitologically confirmed cases of visceral leishmaniasis (kala-azar) in Bihar, India, were treated daily with 20 mg sodium stibogluconate/kg for 30 days, to assess the current efficacy and toxicity of this 30-day regimen. Clinical and parasitological cure was obtained in 48 (60%) of the patients. However, 26 (33%) patients did not respond to the first course of treatment (primary unresponsiveness), two relapsed after initial clinical and parasitological cure, and two were withdrawn from the study (one on day 6 of treatment because of cardiotoxicity in the form of supraventricular tachycardia and the other on day 24 because of severe loss of appetite). All 30 patients who were not entirely cured with sodium stibogluconate were successfully treated with amphotericin B. Electrocardiographic changes occurred in many of the patients as the result of treatment with sodium stibogluconate. Diminution in the height of the T wave was seen in 32 (40%), inversion of the T wave (Minnesota code 5-1, 5-2) in seven (9%), elevation of the ST segment (Minnesota code 4-1) in three (4%), prolonged QT interval (compared with baseline findings) in six (8%), and diminution in the height of the P, R and T waves in two (3%). Cardiac arrhythmia occurred in five patients (6%), supraventricular arrhythmia (coarse atrial fibrillation) occurred in one patient and ventricular tachycardia, ventricular fibrillation, torsade de pointes and multifocal ventricular ectopics occurred in the four patients (5%) who died of cardiotoxicity. Minor side-effects, such as pain at the site of injection (two cases), mild diminution in appetite (12 cases), metallic taste in mouth (six cases), and joint pain (two cases), were also observed. It was concluded that the efficacy of sodium stibogluconate in the study area has declined over the years and that its toxicity has increased. A more efficacious, safer and cheaper, alternative drug is required as the first line of treatment of kala-azar.

Amphotericin B is superior to sodium antimony gluconate in the treatment of Indian post-kala-azar dermal leishmaniasis

Parasitologically confirmed cases of post-kala-azar dermal leishmaniasis (PKDL) were treated by infusion with amphotericin B deoxycholate (ABD; 1 mg/kg.day on days 1-20, 21-40 and 61-80) or by intramuscular injection with sodium antimony gluconate (SAG; 20-day courses at 20 mg/kg day, with 20-day, drug-free intervals). Of the 11 patients given ABD, all were cured with the three courses, none relapsed in 12 months of follow-up, all developed mild adverse effects (shivering and fever) because of the infusion, five lost their appetites, and three showed increases in their serum creatinine concentrations (although none exceeded 'normal' limits). In contrast, only seven (63%) of the 11 patients given SAG were considered treatment successes (improvement in lesions by the end of the third course) and these took six courses (two cases), nine courses (four cases) or 10 courses (one case) to cure completely. Two of the patients given SAG developed arthralgia and two others developed non-specific ST changes in their electrocardiograms (ECG), although their ECG were normal between courses. The better cure rate with ABD was not statistically significant, probably because of the small sample size. However, ABD appears to be a superior to SAG in terms of the speed of response and cure, although it is more expensive and has some nephrotoxicity. As the effectiveness of SAG against PKDL is apparently declining over time and the cost of ABD is prohibitive in poor countries such as India, a safe, cheap and more effective drug for the treatment of PKDL is needed.

The impact of Ixodiphagus hookeri, a tick parasitoid, on Amblyomma variegatum (Acari: Ixodidae) in a field trial in Kenya

In an experiment to investigate the effect of the tick parasitoid, Ixodiphagus hookeri, on tick numbers on cattle, 150000 parasitoids were released over a period of 1 year in a field where ten cattle infested with multiple tick species were kept. Amblyomma variegatum was reduced from 44 to two ticks per animal while Rhipicephalus appendiculatus increased over the time of parasitoid release. During the time of release 51% of the nymphs of A. variegatum collected from the animals were parasitized. The recovery of the parasitoids after the releases were stopped was only 9%. The total numbers of A. variegatum remained low up to 1 year after the parasitoid release was stopped. This study gives an insight into how I. hookeri could be used strategically for the management of A. variegatum on small-scale farms.

Payer-hospital collaboration to improve patient satisfaction with hospital discharge

BACKGROUND

Brigham and Women's Hospital, in Boston, and its major health maintenance organization (HMO), Harvard Community Health Plan, collected data in spring 1994 which revealed that patients were less satisfied with hospital discharge planning than with other elements of care.

PROBLEM IDENTIFICATION PROCESS

An interdisciplinary team, formed in November 1994 and composed of eight members from the hospital and HMO, used data from the hospital's Patient Satisfaction Survey, flowcharting, and phone interviews with patients to identify discharge planning-related problems. For example, follow-up contact with patients after discharge was erratic and no clear signal of the successful "hand off" of care from the hospital team to the community team existed.

IMPROVEMENT CYCLE 1

Eighty-three percent of the payer's patients that received the improvement strategy developed by the interdisciplinary team-a concierge service-rated discharge planning as excellent or very good, compared to 63% of control patients. IMPROVEMENT CYCLE 2: PLAN SOLUTIONS/STRATEGIES FOR IMPROVING HOSPITAL DISCHARGE PLANNING: The results of the team's Cycle 1 improvement provided information for the team to use in designing a second cycle of incremental improvement activity. For example, to address the lack of clarity about who was responsible for making decisions about discharge and follow-up care, the attending physician was designated the transition-of-care coordinator. Once all the improvements were implemented, Cycle 2 patients who received the intervention rated satisfaction with discharge higher (83% versus 73%) than the control group.

CONCLUSIONS

Implications of hospitalwide implementation of discharge planning-related services attempted on one unit are being considered.

Botulinum toxin-induced myopathy in the rat

We have used histological and histochemical techniques at the light microscopical level, and electron microscopy to examine the myopathological changes in rat muscle up to 30 weeks following botulinum toxin injection. Apart from muscle fibre atrophy and related myofibrillar structural changes, the results show a number of striking abnormalities which developed and disappeared at different stages. During the first 4 weeks after toxin injection, vacuoles of variable size were seen in the sarcoplasm near myonuclei, both at and away from endplates. Following this, between 4 and 10 weeks post-injection, progressive degeneration of junctional folds and separation of some nerve terminals from the simplified postsynaptic membranes were observed. At different time points following recovery from the toxin-induced paralysis (evidenced by the increase in muscle fibre size and return of function) a number of abnormalities were still detectable in muscle fibres. These included the appearance within them of multiple arrays of sarcotubular profiles, focal areas lacking myofibrillar organization and mitochondria, abnormal mitochondrial aggregates showing crystalline inclusions, and extension of the postsynaptic densities along the full depth of junctional folds. Furthermore, targetoid-like areas were detected histochemically following recovery from the toxin-induced paralysis. The early extensive vacuolation of the sarcoplasm and the degeneration of junctional folds suggest a myotoxic effect of botulinum toxin. The late changes are likely to be (at least in part) related to the process of recovery following reinnervation.

Calcitonin gene-related peptide-like immunoreactivity, in botulinum toxin-paralysed rat muscles

Changes in calcitonin gene-related peptide-like immunoreactivity (CGRP-LI) at the motor endplates of botulinum toxin-paralysed rat muscles were investigated using immunohistochemistry. One day following toxin injection, a dramatic increase in CGRP-LI was detected at the motor endplates and within preterminal axons of the soleus and gastrocnemius muscles. The upregulation of CGRP-LI persisted throughout the period during which muscle fibres were paralysed and new neuromuscular junctions were being formed by the growing sprouts. Decline of CGRP-LI at the motor endplates coincided with clinical recovery. Both up- and down-regulation of CGRP-LI took place earlier in the soleus than in the gastrocnemius muscle. Up-regulation of CGRP-LI was also detected in a subpopulation of motor axons in the sciatic nerves and in the spinal motor neurons innervating the paralysed muscles. These results indicate that levels of CGRP are regulated, at least partly, by changes in the target innervation. They also suggest an important role for CGRP in the regenerative processes following muscle paralysis.