Activation of human neutrophils by mycobacterial phenolic glycolipids

The interaction between mycobacterial phenolic glycolipids (PGLs) and phagocytes was studied. Human neutrophils were allowed to interact with each of four purified mycobacterial PGLs and the neutrophil production of reactive oxygen metabolites was followed kinetically by luminol-/isoluminol-amplified chemiluminescence. The PGLs from Mycobacterium tuberculosis and Mycobacterium kansasii, respectively, were shown to stimulate the production of oxygen metabolites, while PGLs from Mycobacterium marinum and Mycobacterium bovis BCG, respectively, were unable to induce an oxidative response. Periodate treatment of the M. tuberculosis PGL decreased the production of oxygen radicals, showing the importance of the PGL carbohydrate moiety for the interaction. The activation, however, could not be inhibited by rhamnose or fucose, indicating a complex interaction which probably involves more than one saccharide unit. This is in line with the fact that the activating PGLs from M. tuberculosis and M. kansasii contain tri- and tetrasaccharides, respectively, while the nonactivating PGLs from M. marinum and M. bovis BCG each contain a monosaccharide. The complement receptor 3 (CR3) has earlier been shown to be of importance for the phagocyte binding of mycobacteria, but did not appear to be involved in the activation of neutrophils by PGLs. The subcellular localization of the reactive oxygen metabolites formed was related to the way in which the glycolipids were presented to the cells.

In vitro measurement of the tracking pattern of the human patella

This study sought to determine whether a general pattern describing the three-dimensional tracking characteristics of the human patella could be established, and if not, then to determine the extent and nature of interspecimen variations in the characteristics in a normal population. Using 32 fresh-frozen knees subjected to extensor moment magnitudes similar to those in "static-lifting" and "leg-raising against resistance" maneuvers, patellar displacements were measured in the knee extension range 120 to 0 deg. For static-lifting, a constant foot-floor reaction of 334 N was applied. For leg-raising, a constant net quadriceps tension of 668 N was used throughout the extension range. Measurements were taken with a calibrated six-degree-of-freedom electromechanical goniometer and a displacement coordinate system referenced to the geometry of individual specimens. The three patellar displacements in the plane of knee extension/flexion (extension rotation, and anterior and proximal translations) consistently demonstrated the same pattern in the entire knee extension range with an average coefficient of variation of 13 percent. For knee angles greater than 45 deg, the three other displacements (medial-lateral translation, and rotations about the anterior--posterior and proximal--distal axes) followed a general pattern. However, for knee angles less than 45 deg, these displacements differed considerably between specimens for each loading condition, both in terms of magnitude (average coefficient of variation: 70 percent), and direction.

Assessment of liver function by the MEGX test in patients with schistosomiasis and cirrhosis

OBJECTIVES

The aim of this study was to determine the effect of schistosomiasis infection on hepatic function in Egyptian patients with posthepatitic cirrhosis.

DESIGN AND METHODS

Hepatic function, was assessed in 66 Egyptian patients, with (n = 30) and without (n = 36) schistosomal liver fibrosis due to Schistosoma mansoni and in 20 healthy controls, using the monoethylglycinexylidide (MEGX) test. Serum MEGX concentrations were measured before and 5, 15, 30, 60, 120, and 180 min after a lidocaine bolus. The sero-prevalence of antibodies to hepatitis C was also determined in the patients.

RESULTS

MEGX test results were significantly lower in patients than in controls at all time points. MEGX test results declined with advancing Child Class. Receiver operating characteristic (ROC) curve analysis revealed the following areas under the ROC curves for discrimination of Child Class C from Child Classes A/B: 30 min, 0.762; 60 min, 0.743; 120 min, 0.731; 15 min, 0.728; 180 min, 0.728; 5 min, 0.602. Schistosomiasis infection had no influence on MEGX test results when cirrhotic patients with (Schisto+) and without (Schisto-) schistosomiasis were compared. While the prevalence of the hepatitis B surface antigen was only 16.7% (Schisto-) and 26.7% (Schisto+), there was an extremely high sero-prevalence of antibodies to hepatitis C (HCV) in both groups: 88.9% (Schisto-) and 73.3% (Schisto+).

CONCLUSIONS

The association of schistosomal liver fibrosis with cirrhosis does not additionally influence MEGX formation. In addition, HCV rather than schistosomiasis infection must be considered as a major cause for the progressive liver disease in these patients.

Calculated stress-shielding in the distal femur after total knee replacement corresponds to the reported location of bone loss

This study sought to determine the similarities between features of calculated stress-shielding and observed bone loss in the distal femur after total knee replacement. Stress-shielding was determined by comparing the magnitudes and distributions of strain energy density, calculated using three-dimensional finite element models of the intact bone, the bone after total knee replacement with bonding assumed at all prosthesis-bone interfaces, and the bone after total knee replacement with bonding assumed only at the distal interface. The loading condition simulated static lifting with the knee flexed at 45 degrees, producing tibiofemoral and patellofemoral joint reactions of 900 and 450 N, respectively. The maximum magnitudes of strain energy density calculated using the total knee replacement models were less than 15% of the corresponding magnitudes from the intact bone model. The greatest difference was found to occur at the anterior distal corner of the femur, suggesting this location as the one most vulnerable to stress-shielding. Clinically observed bone loss after total knee replacement frequently occurs at this location. At the anterior distal corner, the calculated magnitudes for the two total knee replacement models were similar, suggesting that stress-shielding at this location was not reduced by limiting fixation only to the distal interface. Although the study corresponded to one loading condition and one geometry of the total knee replacement femoral component with the inherent limitations of model calculations, the results suggest a possible scenario for stress-shielding.

Patients' perception of public, voluntary and private dispensaries in rural areas of Tanzania

Eighty percent of rural dispensaries are run by the government and 19% by voluntary organisations that charge for some services. After the re-legalisation of the private health sector in 1991, private dispensaries are also emerging in villages. Privatisation is among the health reform policies of the country. Moreover, cost-sharing will be introduced at public dispensaries soon. Perception of 320 patients in the Coast Region of Tanzania on services delivered by the three health sectors has been investigated. Results show that patients are generally satisfied with the services and they would go back to the same dispensaries for treatment. Polydrug prescription was common in all sectors, while lack of prescribed drugs was a main complaint among public dispensaries patients. Voluntary dispensaries patients were less satisfied with long waiting time and with staff that did not give them enough information about the treatment. Currently, health service in public dispensaries is free but cost-sharing will be introduced soon. Most of voluntary and private dispensaries patients stated that the fees for service were moderate. The paper discusses the need for monitoring the implementation of cost sharing in public dispensaries to ensure equity in access to services by rural patients.

Longterm outcome of endoscopic sclerotherapy of variceal bleeding: comparative study between schistosomiasis and others

BACKGROUND/AIMS

This comparative study was conducted on 111 patients to evaluate the long term outcome of endoscopic variceal therapy in patients with portal hypertension, and particularly with schistosomiasis.

PATIENTS AND METHODS

There were 45 patients with chronic liver disease due to schistosomiasis, 31 with chronic hepatitis B and 21 with chronic NNb hepatitis. The remaining 14 had chronic liver disease of other etiologies. The mean follow up period was 40 months.

RESULTS

Esophageal varices were completely sclerosed in 32 out of 111 patients in 5 sessions (average) over a mean duration of 8 months. A comparison of patients with schistosomal and non-schistosomal liver diseases revealed that 68% of the schistosomal group patients were in child's A classification, compared to 30% of the patients in the non-schistosomal group. There was no significant difference with respect to early rebleeding and recurrence of oesophageal varices. The outcome of sclerotherapy in schistosomal group was better with respect to survival span over a 5 year period of 78% while for the nonschistosomal group it was less than 59%.

CONCLUSIONS

This study has shown that injection sclerotherapy for bleeding oesophageal varices gives best results when liver function is usually well preserved and for chronic schistosomal liver disease.

Does health information alone help in equitable distribution of essential drug kits between health units at district level?

In Tanzania, the essential drugs programme (EDP) faces acute shortage of drugs brought about by a deteriorating economy and an expanding primary health care system. Many health units complain of shortages of drugs but no increase in the district allocation of EDP kits is foreseen. In the light of the aforementioned problem, a study was carried out in the Kisarawe district of Tanzania to discover, on behalf of the District Health Management Team (DHMT), the extent of the maldistribution with a view to reallocate the EDP kits among the health units on the basis of workload and catchment population. The relative workload of each health unit was estimated from the number of outpatient attendants and the catchment population estimates are based on a 1988 national census. An equitable distribution of EDP kits for each indicator was then developed by ranking the health units in order of workload and catchment population and dividing up the available number of EDP kits proportionately. Health units were categorised as either 'over-allocated', 'appropriately-allocated' or 'under-allocated' with EDP kits by comparing their actual drug supply with the equitable supply. The findings were presented to a meeting of the DHMT attended by the Regional Medical Officer and Ministry of Health officials. Despite being presented evidence of astounding inequity in drug distribution, there was a marked reluctance on the part of the DHMT to decide upon actions to redress some of the imbalance. In this study, we demonstrated that although data from the routine information system on essential drugs at peripheral health units provided sufficient information for managerial purposes, decision-making was delayed and limited. Several possible reasons for this are discussed.

Tensile stress-strain characteristics of the human meniscal material

The nonlinear stress-strain characteristics of the human menisci were determined by uniaxial elongation tests performed on circumferential and radial specimens prepared from different regions, layers, and locations. The properties of the collagen fibers and the matrix were calculated using the test results along with the values of the volume fractions of the meniscal components. Regression analysis showed that only three parameters, the elastic modulus, the maximum strain, and the strain intersect, are sufficient to define the nonlinear stress-strain relation up to failure. For radial specimens, the layer had a significant effect (p < 0.01) on the elastic modulus and the maximum strain, but had no effect on the strain intersect and the maximum stress. For the same specimens, the region had a significant effect (p < 0.01) only on the strain intersect and the maximum stress. For circumferential specimens, analysis indicated no significant effect of either the region, the layer, or the location of the specimens on the material parameters defining the stress-strain relation.

Protean manifestation of gastrointestinal tuberculosis: report on 130 patients

Over the past 8 years, 820 patients with tuberculosis were seen at the Armed Forces Hospital, Riyadh, Kingdom of Saudi Arabia. A total of 292 of these patients (35.6%) had pulmonary tuberculosis, and 130 patients (15.8%) had alimentary tract tuberculosis, making this the second commonest site of involvement. In these 130 patients, the disease was located in the upper gastrointestinal tract in 11 patients (8.5%), small bowel 44 patients (33.8%), large bowel 29 patients (22.3%), peritoneum 40 patients (30.7%), and liver 19 patients (14.6%). The diagnosis in most patients was made by specimens from endoscopy or laparoscopy, or liver or surgical specimens. Gastrointestinal tuberculosis is not uncommon in developing countries, and its incidence is increasing in developed countries due to immigration and in patients with AIDS or those receiving immunosuppressive therapy. It can mimic any diseases affecting the gastrointestinal tract and may present with very different symptoms, so a high index of suspicion is required.

Alpha interferon in treatment of chronic hepatitis C viral infection (CHCV): Pilot study of 18 patients

Eighteen patients with chronic hepatitis C virus infection (CHCV) were treated with three million units of interferon (IFN) three times a week for a minimum of six months. Four (22.2%) had completely responded, two (11.1%) had partial response and the rest (eight or 44.4%) did not show any evidence of response. After stopping treatment, patients who had a complete or partial response developed a relapse during the follow-up period. Few reversible adverse effects of treatment were reported in more than half of the patients. So, we conclude that three million units of IFN three times weekly is not recommended for treating patients with CHCV. Perhaps a larger dose of five to six million units should be tried and for a longer duration.

The management of health services in Tanzania: a plea for health sector reform

There are essentially four main approaches used in attempts to strengthen the management of health services in developing countries. These are: information system development; management training; use of planning and evaluation methodologies; and, health sector reform. As part of a collaborative research project based in Kisarawe District, Tanzania, we tested the hypothesis that a combination of the first three of these approaches would be sufficient to ensure that decisions and actions were taken to bring about major improvements in the management of health services. It was assumed that the decentralization, which took place as part of the 1982 reorganization of local government responsibilities, had provided managers with sufficient decision-making autonomy to allow them to bring about improvement in health service performance, provided that the other conditions were met. In fact, it was found that despite being presented with clear evidence of serious inefficiencies and inequities in the allocation of health resources, managers were often highly reluctant to decide upon actions which would alleviate the problems in situations where there were potential losers as well as winners, even if the benefits greatly outweighed the costs. This article argues that interventions based solely on training, information systems, or planning and evaluation protocols will make only marginal improvements to health service management, and that changes to the system as a whole are needed in order to provide managers and health professionals with incentives to rectify performance failings. Some ideas for health sector reform, to give managers power and incentives for improving efficiency and quality of care, are put forward. Since it is likely that the systemic problems of the health sector in Tanzania are shared by many other developing countries, the lessons drawn from this study probably have more general applicability.

Helicobacter pylori: Prevalence in 352 consecutive patients with dyspepsia

At the Riyadh Armed Forces Hospital (RAFH), 352 patients had gastroscopy and from each, antral gastric biopsies were taken for identification of Helicobacter pylori, by urease test and histopathology. In 217 (61.64%) of these 352 patients, the histology specimens showed Helicobacter pylori in 73.68% of patients with duodenal ulcer, 70% of patients with gastric ulcers and gastric erosions, 61% of patients with duodenitis and 52% of patients with gastritis. The urease test was positive at six hours in 164 (49.59%) of these 352 patients. The urease test was positive in 60% of each group of patients with endoscopic findings of gastric erosions, gastric ulcers and duodenal erosions.

Helicobacter pylori: incidence and comparison of three diagnostic methods in 196 Saudi patients with dyspepsia

One hundred and ninety-six symptomatic Saudi patients with dyspepsia underwent gastroscopy, and multiple biopsies were taken from the antrum of the stomach for identification of Helicobacter pylori. Three methods were studied for diagnosis of Helicobacter pylori, including urease test, culture and histopathology. The commonest gastroscopic findings were gastritis in 82 patients (41.84%) and duodenal ulcer in 40 patients (20.41%). Among the 196 patients, Helicobacter pylori was identified by histopathology in 145 patients (73.98%), the urease test was positive in 126 patients (64.29%), and a positive culture was obtained in 102 patients (52.04%). These results show that there is a high incidence of Helicobacter infection among Saudi patients with peptic ulcer disease or non-ulcer dyspepsia. Helicobacter pylori identification was more successful by histopathology than by the urease test or culture.

Frequency of gastroesophageal reflux in patients with liver cirrhosis

Twenty-five adult patients with liver cirrhosis, and another 30 patients with no liver disease but referred with symptoms suggestive of gastroesophageal reflux disease were selected at random. Twenty-four hour ambulatory intra-esophageal pH measurement and upper gastrointestinal endoscopy were carried out on all patients recruited. Applying the former test, 16 (64%) of the patients with liver cirrhosis have gastroesophageal reflux disease. This figure is comparable with the 70% (21/30) rate recorded in the group of dyspeptic patients clinically thought to have the disorder. A positive endoscopic diagnosis was much lower at 12% and 23%, respectively. No significant differences were observed among liver disease patients when they were subdivided in accordance with the etiology of liver cirrhosis and the grade of esophageal varices. We conclude that gastroesophageal reflux disease occurs at a high frequency (64%) in patients with liver cirrhosis and portal hypertension, irrespective of the etiology of cirrhosis and the grade of esophageal varices. It is therefore considered to be the main cause of esophagitis in these patients, and that it might play a role in initiating a variceal bleeding episode. The latter hypothesis needs further evaluation.

The return of life-threatening puerperal sepsis caused by group A streptococci

A dramatic decline in the prevalence of serious puerperal infection caused by group A beta-hemolytic streptococci has been observed throughout most of the twentieth century, and it is currently a very uncommon cause of maternal morbidity and mortality. We report on two term pregnancies complicated by profound multisystem organ failure caused by group A streptococcal puerperal sepsis. This report serves to highlight the apparent return of serious group A streptococcal puerperal sepsis and to emphasize the clinical implications and sequelae attributable to an old yet virulent enemy.

Design and development of an unconstrained dynamic knee simulator

A dynamic knee simulator has been developed to allow in-vitro investigation of the mechanical response of the joint corresponding to dynamic functional activities, e.g., walking. In the simulator, the controlled inputs are the time-histories of three parameters of a given dynamic activity: the flexion angle, and the flexion/extension moment and tibial axial force components of the foot-to-floor reaction. A combination of stepping motors and electro-hydraulic actuators is used to apply to a knee specimen, simultaneously and independently, the specified load and/or displacement inputs while allowing unconstrained relative motion between the joint members. Satisfactory performance of the simulator has been established for walking gait conditions based on measurements on three fresh-frozen specimens.

Socio-economic determinants of labour mobility in Pakistan

"With the availability of Population, Labour Force, and Migration (PLM) Survey data, this paper attempts to develop a model of internal [labor] migration in Pakistan.... Keeping in line with the literature, three types of variables have been identified as the possible determinants of migration. These variables relate to the possession of human capital, commitment to job and place of residence, and cost-related factors. After controlling for other variables, it was observed that, in general, migrants were selective especially in terms of age, education, and choice of occupation. These findings are consistent with the evidence from other developing countries."

Ligament tension pattern in the flexed knee in combined passive anterior translation and axial rotation

Twenty-two fresh-frozen specimens were used to measure tensions generated in selected bands of the major ligaments of the flexed knee (40-90 degrees) when an axially prerotated tibia is subjected to passive anterior shear and when an anteriorly pretranslated tibia is subjected to passive axial torque. The tensions were measured using the buckle transducer attached to the anteromedial band of the anterior cruciate ligament [ACL (am)], the posterior fibers of the posterior cruciate ligament [PCL (pf)], the long fibers of the medial collateral ligament [MCL (lf)], and in the total lateral collateral ligament [LCL]. The knee specimens were subjected to the combined motions in a 6-df passive loading apparatus. The results indicated that the joint resistance to anterior translation increased markedly with internal prerotation and only marginally with external prerotation. This increase in joint resistance, however, was associated with a decrease in ACL function. It has been inferred that the posterior structures, capsular and meniscal, contribute significantly to joint resistance when the tibia is prerotated in either sense. For internal prerotation, the interference between the medial femoral condyle and the central tibial eminence was found to be an additional mechanism of resistance to anterior translation. Also, it has been found that although the ACL (am) tension increased with internal rotation in the normal case, it decreased with internal rotation in the presence of an anterior pretranslation. It is concluded that ACL response to combined joint motion cannot be ascertained by a simple summation of its responses to individual motions.

Endoscopic choledochoduodenostomy (ECDT): A practical approach to management of impacted papillary gallstones and ampullary tumors

We report five cases of impacted papillary stones and two cases of ampullary carcinoma treated by endoscopic choledochoduodenostomy (ECDT) at Riyadh Armed Forces Hospital (RAFH). The procedure was carried out successfully in all five cases with impacted stones and in one of the two cases of ampullary carcinoma. No complications were noted. In the presence of the necessary endoscopic expertise and in cases of impossible cannulation of the papilla of Vater due to stone impaction or the presence of a papillary tumor, we recommend endoscopic choledochoduodenostomy (ECDT). This approach provides an access to the common bile duct thus following appropriate therapeutic procedurs on the biliary system to be performed.

The association between hepatitis C virus antibody and hepatocellular carcinoma in relation to hepatitis B viral infection (RAFH experinece)

Forty-two patients with hepatocellular carcinoma (HCC) were seen during two years at Riyadh Armed Forces Hospital (RAFH), Saudi Arabia. As viral hepatitis is common in this country, serological markers for hepatitis B virus (HBV) and the newly identified hepatitis C virus (HCV) were also studied in these patients. Fourteen (33.3%) patients were HBsAg positive, 11 (26.2%) were anti-HCV positive, two (4.8%) were positive for both HBsAg and anti-HCV and five (11.9%) were anti-HBc and anti-HBs positive. The remaining ten patients all were negative for markers. Serological markers were also studied in 1472 blood donors (control group) during the same period. Twenty-two (1.5%) were positive for anti-HCV, 59 (4%) for HBsAg and two (0.1%) for both markers. Our results are in accordance with previous studies carried out elsewhere, and it is suggested that hepatitis C virus like hepatitis B, may play an important etiological role in hepatocellular carcinoma in Saudi Arabia.