Towards sustainable delivery of health services in Afghanistan: options for the future

Disruption caused by decades of war and civil strife in Afghanistan has led many international and national nongovernmental organizations (NGOs) to assume responsibility for the delivery of health services through contracts with donor agencies. Recently the Afghan Government has pursued the policy of contracting for a basic package of health services (BPHS) supported by funds from three major donors-the World Bank, the United States Agency for International Development (USAID) and the European Commission. With the gradual strengthening of the public health ministry, options for the future include pursuing the contracting option or increasing public provision of health services. Should contracting with NGOs be pursued, a clear strategy is required that includes developing accreditation instruments, better contracting mechanisms and a system for monitoring and evaluating the entire process. Should the government opt for an increasing role, problems to be solved include securing the transition to public provision, optining guarantees that appropriate financing will be provided and reconfiguration of the public health delivery system. Large-scale contracting with the private for-profit sector cannot be recommended at this stage, although this option could be explored via subcontracting by larger NGOs or small-scale trial contracts initiated by the public health ministry. Irrespective of the option chosen, an important challenge remaining is the recalcitrant problem of high out-of-pocket payments. Sustainable delivery of health services in Afghanistan can only be achieved with a clear national strategy in which all stakeholders have roles to play in the financing, regulation and delivery of services.

Deficiencies in medical prescriptions in a Sudanese hospital

We determined the quality of medical prescription in Ribat University Hospital, Khartoum through detecting errors in doctors' prescriptions. We randomly selected 1000 medical prescriptions and checked them for completeness and legibility. The total number of doctors responsible for writing the prescriptions was 46. The patient's full name was written on only 18.8% of prescriptions and that of the doctor on only 6.7%. In only 19.5% of prescriptions were drugs prescribed by their generic names, 59.7% lacked the quantity of the drug, 25.7% lacked the duration of treatment and 15.8% were difficult to read. The quality of drug prescriptions written by our hospital doctors is seriously deficient.

Attitudes towards euthanasia among final-year Khartoum University medical students

To investigate the attitudes of final-year medical students at Khartoum University towards euthanasia an anonymous questionnaire was answered by 141 students. Most were familiar with the concept of euthanasia. The majority, 108 (76.6%) opposed euthanasia and their reasons included religious beliefs, belief that euthanasia was unethical and fear of misuse. The supporters of euthanasia (23.4%) stated reasons such as preventing the suffering of patients and respecting their autonomy and dignity. More students who described themselves as strongly religious were opponents of euthanasia (83/87, 95.4%) than those who were moderately religious (25/54, 46.3%).

History of disorders of thyroid dysfunction

The first description of thyroid diseases as they are known today was that of Graves disease by Caleb Parry in 1786, but the pathogenesis of thyroid disease was not discovered until 1882-86. Thyroidectomy for hyperthyroidism was first performed in 1880, and antithyroid drugs and radioiodine therapy were developed in the early 1940s. Thomas Curling first described hyopothyroidism (myxoedema) in 1850 and the cause and suitable treatment were established after 1883. This paper reviews the main landmarks in the history of thyroid disease, supplemented by a brief discussion of the historically relevant scientific aspects of the thyroid gland, and the evolution of endocrinology as a formal discipline.

A study of domestic violence among women attending a medical centre in Sudan

To investigate domestic violence in the Sudanese family, we studied 394 literate, married women attending the Arda Medical Centre, Omdurman, from October 2001 to February 2002. Through self-administered questionnaires, the women provided data on sociodemographic characteristics and abuse by the husband. Abuse was reported by 164 women (41.6%), who suffered 525 violent episodes in the previous year, classified into controlling behaviour (194), threatening behaviour (169) and physical violence (162). Frequency of violent episodes varied from 1 (25%) to > 6 (20.7%). Violence during pregnancy was reported by 27 women (16.5%). Provoking events included suspicion of illicit relations, talking back and inadequate home care. Common reactions reported by the women included staying quiet, crying and resistance.

Three-dimensional morphometry of the femoral condyles

OBJECTIVE

The present study describes the geometry of the three-dimensional articular surfaces of the human femoral condyles based on measurements of surface coordinates.

DESIGN

The purpose was not to obtain a complex representation of one single condyle, but to describe the femoral condyles using simple geometric parameters based on measurements using a number of specimens.

BACKGROUND

In joint modeling, a representative knee joint geometry is often desired which requires an approximation of the irregular joint geometry while taking into account interspecimen variations.

METHODS

An optical device was used to measure the condylar articular surfaces of 12 human femurs in the femorotibial contact region. The sagittal profiles were reconstructed by means of two circular arcs and the radial profiles by means of one circular arc.

RESULTS

The results provide the geometric parameters necessary for the three-dimensional reconstruction of the articular surfaces of the femoral condyles. The results indicate that the medial and lateral condyles of the distal femur are significantly asymmetric in a number of morphological features.

CONCLUSION

The primary application of the results is expected to be in the formulation of finite element models of the knee joint for static contact problems.

RELEVANCE

Numerical models of the knee joint are being widely used to study the mechanics of the joint. However, formulation of such models demands a prior knowledge of the complex three-dimensional geometry of the articular surfaces of the natural joint to establish the input parameters of the model.

In vitro measurement of the restraining role of the anterior cruciate ligament during walking and stair ascent

The study aimed to test the hypothesis that the restraining role of the anterior cruciate ligament (ACL) of the knee is significant during the activities of normal walking and stair ascent. The role of the ACL was determined from the effect of ACL excision on tibiofemoral displacement patterns measured in vitro for fresh-frozen knee specimens subjected to simulated knee kinetics of walking (n = 12) and stair ascent (n = 7). The knee kinetics were simulated using a newly developed dynamic simulator able to replicate the sagittal-plane knee kinetics with reasonable accuracy while ensuring unconstrained tibiofemoral kinematics. The displacements were measured using a calibrated six degree-of-freedom electromechanical goniometer. For the simulation of the walking cycle, two types of knee flexion/extension moment patterns were used: the more common "biphasic" pattern, and an extensor muscle force intensive pattern. For both of these patterns, the restraining role of the ACL to tibial anterior translation was found to be significant throughout the stance phase and in the terminal swing phase, when the knee angle was in the range of 4 degrees to 30 degrees. The effect of ACL excision was an increase in tibial anterior translation by 4 mm to 5 mm. For the stair ascent cycle, however, the restraining role of the ACL was significant only during the terminal stance phase, and not during the initial and middle segments of the phase. Although, in these segments, the knee moments were comparable to that in walking, the knee angle was in the range of 60 degrees to 70 degrees. These results have been shown to be consistent with available data on knee mechanics and ACL function measured under static loading conditions.

Internal migration, earnings, and the importance of self-selection

This paper analyzes the impact of internal migration on earnings within the human capital model framework. Since migrants constitute a non-random sample of population, the endogenous nature of migration decision warrants necessary correction for the selectivity bias in their earnings function. The Mincer-type earnings model is thus augmented to determine the extent of this bias. Besides estimating the standard Mincerian earnings model, the paper also attempts to verify the learn-as-you-go proposition by introducing migration duration variables in the earnings model. Based on the household level Population, Labor Force, and Migration (1979-80) survey data, the analysis yields the following important conclusions: (i) the data allowed a meaningful estimation of Mincerian earnings function for migrants and non-migrants; (ii) the level of schooling was one of the important determinants of the distribution of income both for migrants and nonmigrants--the four categorical variables of education were in general statistically significant with expected signs, implying that the hypothesis of a positive relationship between income and education was accepted; (iii) the rates of return to education improved systematically with higher levels of education, thus confirming the notion that education serves as a signalling device; (iv) the age-income profile was almost linear for migrants but showed concavity for nonmigrants; (v) the presence of sample-selection was observed for migrants; and (vi) even after controlling for the influence of personal characteristics, i.e., education and experience, the long-standing migrants earned relatively more at the destination than the more recent migrants.

Evaluation of groundwater and soil pollution in a landfill area using electrical resistivity imaging survey

Landfills are sources of groundwater and soil pollution due to the production of leachate and its migration through refuse. This study was conducted in order to determine the extent of groundwater and soil pollution within and around the landfill of Seri Petaling located in the State of Selangor, Malaysia. The condition of nearby surface water was also determined. An electrical resistivity imaging survey was used to investigate the leachate production within the landfill. Groundwater geochemistry was carried out and chemical analysis of water samples was conducted upstream and downstream of the landfill. Surface water was also analyzed in order to determine its quality. Soil chemical analysis was performed on soil samples taken from different locations within and around the landfill in the vadose zone (unsaturated zone) and below the water table (in the soil saturated zone). The resistivity image along line L-L1 indicated the presence of large zones of decomposed waste bodies saturated with highly conducting leachate. Analysis of trace elements indicated their presence in very low concentrations and did not reflect any sign of heavy metal pollution of ground and surface water or of soil. Major ions represented by Na, K, and Cl were found in anomalous concentrations in the groundwater of the downstream bore hole, where they are 99.1%, 99.2%, and 99.4%, respectively, higher compared to the upstream bore hole. Electrical conductivity (EC) was also found in anomalous concentration downstream. Ca and Mg ions represent the water hardness (which is comparatively high downstream). There is a general trend of pollution towards the downstream area. Sulfates (SO4) and nitrates (NO3) are found in the area in low concentrations, even below the WHO standards for drinking water, but are significantly higher in the surface water compared to the groundwater. Phosphate (PO4) and nitrite (NO2), although present in low levels, are significantly higher at the downstream. There is no significant difference in the amount of fluoride (F) in the different locations. In the soil vadose zone, heavy metals were found to be in their typical normal ranges and within the background concentrations. Soil exchangeable bases were significantly higher in the soil saturated zone compared to the vadose zone, and no significant difference was obtained in the levels of inorganic pollutants. With the exception of Cd, the concentration ranges of all trace elements (Cu, Zn, Cr, Pb, and Ni) of Seri Petaling landfill soils were below the upper limits of baseline concentrations published from different sources.

MALARIA-INDUCED APOPTOSIS IN MOSQUITO OVARIES

Many insects are able to adjust their egg production according to physiological conditions such as nutrient supply and mating success. One way in which this is achieved is by resorption of some, or all, of the ovarian follicles at some stage during oogenesis. We have shown that the mosquito Anopheles stephensi responds in this manner when ookinetes of the malaria parasite Plasmodium yoelii nigeriensis first begin to invade the midgut. Little is known about the initiation and regulation of follicle resorption in any insect. Here, we demonstrate that there is a significant positive correlation between follicle resorption and the presence of follicular epithelial cells that are undergoing apoptosis. The parasite causes significantly more follicles to contain apoptotic cells from 16 h post-infection onwards. Injection of a caspase inhibitor immediately after feeding on an infective blood meal prevents parasite-induced resorption of follicles and thus demonstrates that apoptosis precedes resorption. Ultrastructural studies show that patches of follicular epithelial cells contain condensed nuclear chromatin, a characteristic of apoptosis, and that no patency develops in these cells. Our work suggests that apoptosis plays a role in malaria-initiated inhibition of mosquito oogenesis and that caspase is central to this process. Follicle resorption is one of the main factors contributing to malaria-induced fecundity reduction in mosquitoes.

Effects of malaria infection on vitellogenesis in Anopheles gambiae during two gonotrophic cycles

We report changes in the abundance of vitellogenin (Vg) mRNA, and concentration of haemolymph Vg and ovarian vitellin (Vn) in Anopheles gambiae following infection with Plasmodium yoelii nigeriensis. A parasite-induced reduction in Vg mRNA abundance was first detected 24 h after feeding on an infective blood meal, when ookinetes were invading the midgut. During a second gonotrophic cycle post-infection, developing oocysts reduced Vg mRNA abundance by up to 33% and the effect was detected from 2 h post blood meal. Concentrations of Vg were initially reduced by infection during the second cycle, as predicted from Vg mRNA measurements. However, after 24 h, excess Vg had accumulated in the haemolymph. This accumulation may be due to impaired uptake, since ovarian vitellin accumulation was significantly decreased by infection during both gonotrophic cycles.

Attitudes towards euthanasia and assisted suicide among Sudanese doctors

An anonymous questionnaire was used to survey the attitudes of 382 doctors towards euthanasia and assisted suicide at Khartoum's two main hospitals. Of the 382, 248 responded (65% response rate). The mean age was 38 +/- 13.5 years; male:female ratio was 130:118; 66% were house staff, 34% specialists; 92% Muslim, 8% Christian. The vast majority (85%) strongly opposed the practices, while 15% thought they should be performed only in certain situations, subject to strict safeguards. Reasons given for opposition included religious beliefs, inconsistency with the doctor's role, presence of subtle pressures on patients, and potential for misuse among the physically and intellectually handicapped.

Effect of femoral component designs on the contact and tracking characteristics of the unresurfaced patella in total knee arthroplasty

OBJECTIVES

To determine the effect of 5 different femoral components used in total knee arthroplasty (TKA) on the contact area and tracking characteristics of the nonresurfaced patella and to identify any design features that might adversely affect these characteristics.

DESIGN

An in-vitro study.

SETTING

The biomechanics laboratory, Department of Mechanical Engineering, McGill University, Montreal.

SPECIMENS

Six fresh-frozen cadaveric knee-joint specimens.

INTERVENTIONS

An unconstrained quadriceps simulator was used to apply the conditions of static lifting to the specimens first in their normal state and then sequentially implanted with femoral and tibial components of various designs (Miller/Galante II, Anatomic Modular Knee [AMK] System, Whiteside Ortholoc Modular, press-fit condylar and Insall-Burstein II).

OUTCOME MEASURES

Patellar 3-dimensional tracking characteristics, determined by using a 6 degrees-of-freedom electromechanical goniometer attached directly to the patella, and patellar contact pressure measurements, obtained using low-range Fuji Prescale film.

RESULTS

Articulation of the normal patella on a prosthetic femoral component resulted in alterations in the normal patellofemoral contact and tracking characteristics. The exact departure depended on the design of the prosthetic trochlea. Although all of the selected prostheses demonstrated satisfactory contact characteristics near extension, marked alterations occurred at higher flexion angles. With 90 degrees or more of flexion, there was incompatibility between the geometries of the prosthetic notch of 2 femoral designs (AMK and PFC) and the normal knee.

CONCLUSION

The design of the prosthetic femoral component must be taken into account when determining whether or not to resurface the patella at the time of TKA.

Sagittal profile of the femoral condyles and its application to femorotibial contact analysis

Measurements of the sagittal profiles of the articular surfaces of 24 femoral condyles were performed using a laser range finder. An algebraic algorithm was developed to reconstruct the measured sagittal profiles with simple geometry. In particular, it has been shown that a two-circular-arc model provides a very accurate reconstruction of the actual profiles in the femorotibial contact region. The average sagittal profile was used for a femorotibial contact analysis of TKA implants. The contact analysis was performed by using a rigid-body-spring model extended to the case of nonlinear force-deformation behavior of the tibial polyethylene component.

Thyroid functional status in leprosy patients in Sudan

We studied 45 adult patients with untreated lepromatous leprosy and borderline leprosy, presenting at clinics in Khartoum and Omdurman, to assess clinical and biochemical effects of the disease on thyroid function. A matching control group of 30 subjects, without symptoms or signs of thyroid disease, were included for comparison. Thyroxine, triiodothyronine and thyrotrophin levels were within normal range. Mean serum thyroxine was low in both groups (significant in lepromatous leprosy patients only). Mean serum triiodothyronine was high in both groups (significant in neither group). Mean thyrotrophin was significantly higher in both groups compared with controls.

Diabetic autonomic neuropathy

OBJECTIVE

The diabetic autonomic neuropathy is a poorly studied subject in our medical literature. This study is aimed at investigating the presence of diabetic autonomic neuropathy in a group of Sudanese diabetic patients and its relationship to factors like glycemic control, duration of diabetes and presence of peripheral neuropathy.

METHODS

During one year we examined 120 diabetic patients and an age-matched control group of 42 by applying a battery of 5 cardiovascular autonomic tests, beside a full history and clinical examination. The patients were also tested for glycemic control and presence of peripheral neuropathy.

RESULTS

Diabetic autonomic neuropathy was diagnosed in 48 patients (40%) of a mean age of 48.411 +/- 12.50 years, type 1/2 diabetes was 10/38, mean duration of diabetes 16.2 +/- 7.3 years, 41 with poor glycemic control (81%) and peripheral neuropathy was present in 32 patients (66%). We found a significant association between diabetic autonomic neuropathy and prolonged duration of diabetes (P<0.001), poor glycemic control (0.01>P>0.001) and presence of peripheral neuropathy (0.02>P>0.01).

CONCLUSION

Diabetic autonomic neuropathy (both asymptomatic and symptomatic) is a common problem among our diabetic patients. It is significantly associated with prolonged duration, poor control of diabetes and presence of peripheral neuropathy. We need to augment the awareness of diabetes care providers to the occurrence, and peculiar features and tests of this syndrome.

Correlation of patellar tracking pattern with trochlear and retropatellar surface topographies

The study was aimed to test the hypothesis that in the knee extension range 100 to 30 deg, the patellar "out-of-plane" tracking pattern is controlled by the passive restraint provided by the topographic interaction of the patellofemoral contacting surfaces. The out-of-plane tracking pattern, i.e., the pattern of patellar displacements not in the plane of knee extension/flexion, consists of translation in the medial-lateral direction, and rotations about the anterior-posterior axis (spin) and the proximal-distal axis (tilt). Using 15 fresh-frozen knees subjected to extensor moment magnitudes comparable to those in the "static-lifting" activity (foot-ground reaction = 334 N), the patellar displacements were measured using a calibrated six-degree-of-freedom electromechanical goniometer. The topographies of the trochlear and retropatellar surfaces were then measured using a calibrated traveling dial-gage arrangement and the same coordinate system used for the displacement measurements. Three indices were defined to quantify particular natural features of the three-dimensional topographies that are expected to control the patellar displacements. Correlation of the indices with their corresponding displacements showed that topographic interaction was significant in the control of all three displacements. However, for patellar spin, unlike for the other two displacements, the direction of the active quadriceps tension vector was also a significant controlling factor. Patellar medial-lateral translation was found to be controlled dominantly by the trochlear topography, while retropatellar topography also had a significant role in the control of the other two displacements.

Diabetic autonomic neuropathy

OBJECTIVE

The diabetic autonomic neuropathy is a poorly studied subject in our medical literature. This study is aimed at investigating the presence of diabetic autonomic neuropathy in a group of Sudanese diabetic patients and its relationship to factors like glycemic control, duration of diabetes and presence of peripheral neuropathy.

METHODS

During one year we examined 120 diabetic patients and an age-matched control group of 42 by applying a battery of 5 cardiovascular autonomic tests, beside a full history and clinical examination. The patients were also tested for glycemic control and presence of peripheral neuropathy.

RESULTS

Diabetic autonomic neuropathy was diagnosed in 48 patients (40%) of a mean age of 48.411 + 12.50 years, type 1/2 diabetes was 10/38, mean duration of diabetes 16.2 + 7.3 years, 41 with poor glycemic control (81%) and peripheral neuropathy was present in 32 patients (66%). We found a significant association between diabetic autonomic neuropathy and prolonged duration of diabetes (P<0.001), poor glycemic control (0.01>P>0.001) and presence of peripheral neuropathy (0.02>P>0.01).

CONCLUSION

Diabetic autonomic neuropathy (both asymptomatic and symptomatic) is a common problem among our diabetic patients. It is significantly associated with prolonged duration, poor control of diabetes and presence of peripheral neuropathy. We need to augment the awareness of diabetes care providers to the occurrence, and peculiar features and tests of this syndrome.

Post carotid endarterectomy seizure

Post carotid endarterectomy seizure is a known clinical presentation in patients who suffer from hyperperfusion syndrome. This case focuses on the importance of identification of high risk patients for developing this syndrome and delaying their discharge from the hospital after successful carotid endarterectomy.

Post carotid endarterectomy seizure

Post carotid endarterectomy seizure is a known clinical presentation in patients who suffer from hyperperfusion syndrome. This case focuses on the importance of identification of high risk patients for developing this syndrome and delaying their discharge from the hospital after successful carotid endarterectomy.

Gastroparesis diabeticorum: A clinical study in Sudanese patients

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