Changes in public commons as a consequence of urbanization: the Agara lake in Bangalore, India

The city of Bangalore in southern India is rapidly expanding, resulting in major transformations in land use, wetland management, and the distribution of green spaces. This paper examines how transformations in land use and governance consequent to urbanization can change people's perceptions of and interactions with an urban ecological commons, using the case study of the Agara lake in the south Indian city of Bangalore. In less than four decades, the landscape surrounding the lake has altered from a fundamentally agricultural area, dependent on the lake for irrigation and drinking water, to a densely urbanized area where the lake is used predominantly for recreation. A change in governance from community management to state management has sidelined the fishers, fodder collectors and agricultural users who traditionally maintained this lake. The governmental agencies that are supposed to maintain the lake are unable to do so due to a complex governance structure, with overlapping jurisdictions, compounded by an ongoing litigation. Over the past decades, the lake has largely transitioned into an urban green space primarily used for recreation and nature watching. This case study provides us with a broader understanding of how changes in governance consequent to urbanization and city expansion can impact interactions between people and ecological commons in a rapidly growing Indian city.

Msx1 mutations: how do they cause tooth agenesis?

Mutations in the transcription factors PAX9 and MSX1 cause selective tooth agenesis in humans. In tooth bud mesenchyme of mice, both proteins are required for the expression of Bmp4, which is the key signaling factor for progression to the next step of tooth development. We have previously shown that Pax9 can transactivate a 2.4-kb Bmp4 promoter construct, and that most tooth-agenesis-causing PAX9 mutations impair DNA binding and Bmp4 promoter activation. We also found that Msx1 by itself represses transcription from this proximal Bmp4 promoter, and that, in combination with Pax9, it acts as a potentiator of Pax9-induced Bmp4 transactivation. This synergism of Msx1 with Pax9 is significant, because it is currently the only documented mechanism for Msx1-mediated activation of Bmp4. In this study, we investigated whether the 5 known tooth-agenesis-causing MSX1 missense mutations disrupt this Pax9-potentiation effect, or if they lead to deficiencies in protein stability, protein-protein interactions, nuclear translocation, and DNA-binding. We found that none of the studied molecular mechanisms yielded a satisfactory explanation for the pathogenic effects of the Msx1 mutations, calling for an entirely different approach to the investigation of this step of odontogenesis on the molecular level.

DMP1 processing is essential to dentin and jaw formation

Dentin matrix protein 1 (DMP1), an acidic protein that is essential to the mineralization of bone and dentin, exists as proteolytically processed fragments in the mineralized tissues. In this study, we characterized the tooth and jaw phenotypes in transgenic mice containing no wild-type DMP1, but expressing a mutant DMP1 in which Asp(213), a residue at one cleavage site, was replaced by Ala(213) (named "Dmp1-KO/D213A-Tg" mice). The teeth and mandible of Dmp1-KO/D213A-Tg mice were compared with those of wild-type, Dmp1-knockout (Dmp1-KO), and Dmp1-KO mice expressing the normal Dmp1 transgene. The results showed that D213A-DMP1 was not cleaved in dentin, and the expression of D213A-DMP1 failed to rescue the defects in the dentin, cementum, and alveolar bones in the Dmp1-KO mice. These findings indicate that the proteolytic processing of DMP1 is essential to the formation and mineralization of dentin, cementum, and jaw bones.

Sensitivity of higher, lower and mean second-trimester uterine artery Doppler resistance indices in screening for pre-eclampsia

OBJECTIVES

First-trimester Doppler studies have reported that the lower uterine artery (UtA) resistance index (RI) is better for the prediction of pre-eclampsia (PE) than is either the mean or higher indices. The aim of this study was to determine if this relationship is true in the second trimester.

METHODS

This was a retrospective study of 24 859 singleton pregnancies. During the study period second-trimester UtA Doppler assessment was routinely available to all nulliparous women and to parous women at increased risk of PE. UtA-RI was obtained at the time of the anomaly scan. Receiver-operating characteristics curves for the lower, mean and higher UtA-RI for the prediction of PE were calculated.

RESULTS

There were 1037 cases of PE. There were significant associations between UtA-RI and PE, the association being stronger for early and preterm than late or term PE. There was no significant difference in the strength of the association between lower, mean and higher RI with PE at any gestation.

CONCLUSION

Performance of UtA-RI in predicting PE is no different for the lower, higher or mean RI of the two UtAs. The most likely explanation for the discrepancy with first-trimester studies is that the placental-side effect on Doppler indices may change with advancing gestational age and progressive trophoblast development and invasion.

Regional update: Cambodia

Cambodia is a developing south-east Asian country located in the fertile Mekong delta. Its recent past has been complicated by European colonialism and internal conflict. Health including mental health services are limited and sparse in regional and rural areas. Very constrained public mental health facilities and services are hampered by a shortage of a skilled workforce and insufficient training programs. The recent formation of the Mental Health Association of Cambodia promises to be a positive step forward in promoting mental health throughout the country.

Dietary habits associated with obesity among adolescents in Dubai, United Arab Emirates

AIM

to study the association between the dietary habits and behavioural factors with the increased risk of obesity amongst adolescents in Dubai, United Arab Emirates (UAE).

METHOD

A cross-sectional study was carried out among 661 adolescents (324 boys and 337 girls) aged 12 to 17 years selected by means of a multistage stratified random sampling technique.

RESULTS

The highest percentage of obesity was observed at 14 years of age in boys (30.5%) and at 13 years of age in girls (35.4%). There was a significant association between the frequency of eating breakfast (P =0.048), snacking between breakfast and lunch (P = 0.044), and obesity in girls but not in boys. A high risk of obesity was associated with eating breakfast at school in both boys (OR = 3.0; CI 1.1-8.3) and girls (OR = 3.4; CI 1.6-7.4). Fast foods showed a significant association with obesity in girls (P = 0.007), but not in boys (P = 0.745). The risk of obesity was higher in boys who ate fast foods at home (OR = 1.3; CI 0.5-3.2) but less in girls (OR = 0.2; CI 0.1-1.0).

CONCLUSION

Intervention programs focused on promoting changes in lifestyles, food habits and increasing physical activity need to be implemented at the earliest.

In VitroandIn VivoPreparation Evaluations of Bleomycin Implants and Microspheres Prepared with DL-Poly (Lactide-Co-Glycolide)

In this investigation, poly(lactide-co-glycolide) (PLGA) gel implants and microspheric depot systems of bleomycin (BLM) were formulated and evaluated in vivo in mice bearing transplantable solid tumor (fibrosarcoma). The pharmacodynamic studies showed that both the formulations retarded tumor growth significantly (p<0.05) when compared to the control animals (without any drug treatment). Preliminary pharmacokinetic studies illustrated controlled release of the drug into the systemic circulation to elicit the anti-neoplastic action. The gel implants showed better release characteristics and greater pharmacodynamic action when compared to the microspheres, thus demonstrating the feasibility of employing biodegradable depot polymer gel matrix for chronic cancer therapy.

Genes affecting tooth morphogenesis

The development of dentition is a fascinating process that encompasses a complex series of epithelial-mesenchymal interactions involving growth factors, transcription factors, signal receptors and other soluble morphogens. It is not surprising that such a complex process is prone to disturbances and may result in tooth agenesis. Initial discoveries indicating that the homeo-domain protein MSX1 and the paired-domain transcription factor PAX9 are causative genes in tooth morphogenesis were made in mice. Both genes are co-expressed in dental mesenchyme and either one, when homozygously deleted, results in an arrest at an early developmental stage. Heterozygous Pax9 or Msx1 mice have normal teeth, however, double heterozygous Pax9/Msx1 mice show a phenotype of arrested tooth development which can be rescued by transgenic expression of Bmp4, a very influential signaling factor in many developmental processes. We have obtained mounting evidence for a partnership between PAX9 and MSX1 within the tooth-specific Bmp4 signaling pathway. In humans, unlike in mice, a heterozygous mutation in either PAX9 or MSX1 suffices to cause tooth agenesis of a predominantly molar or more premolar pattern, respectively. Our laboratory and others have identified several PAX9 and MSX1 mutations in families with non-syndromic forms of autosomal dominant posterior tooth agenesis. We have also identified families with tooth agenesis in whom PAX9 and MSX1 mutations have been excluded opening up the possibilities for the discovery of other genes that contribute to human tooth agenesis.

WITHDRAWN: Antibiotics for preventing pneumonia in children with measles

BACKGROUND

Measles causes more than a million deaths a year, of which most are children under five years of age who die from pneumonia.

OBJECTIVES

The objective of this review was to assess the effects of antibiotics given to children with measles on reducing pneumonia or mortality, and to assess whether antibiotics should be given to all children with measles in communities with a high fatality rate.

SEARCH STRATEGY

We searched MEDLINE (1966 - 1999), EMBASE (1980-1999) and the specialized trials register of the Acute Respiratory Infections Group in August 1999, and all relevant journals in the University of Melbourne medical library for the years 1935-46.

SELECTION CRITERIA

Randomised or controlled trials of antibiotics for children with measles.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed trial quality.

MAIN RESULTS

Six trials with 1304 children were included. All but one of the trials were unblinded, and randomisation was either not described or was by alternate allocation. In four studies, the incidence of pneumonia in the control group was similar to that in the antibiotic prophylaxis group; in the other two studies, the incidence of pneumonia was unusually high in the control group so these children had a higher complication rate than the antibiotic group. Four of the 764 children given antibiotics died compared with one of the 637 controls.

AUTHORS' CONCLUSIONS

The quality of the trials reviewed was poor, and they provide very weak evidence for giving antibiotics to all children with measles. Available evidence suggests that antibiotics should be given only if a child has clinical signs of pneumonia or other evidence of sepsis.

The effectiveness and cost-effectiveness of cinacalcet for secondary hyperparathyroidism in end-stage renal disease patients on dialysis: a systematic review and economic evaluation

OBJECTIVES

To establish the effectiveness and cost-effectiveness of cinacalcet for the treatment of secondary hyperparathyroidism (SHPT) for people on dialysis due to end-stage renal disease (ESRD).

DATA SOURCES

Electronic databases were searched up to February 2006.

REVIEW METHODS

Included randomised controlled trials (RCTs) on the clinical effectiveness of cinacalcet for SHPT in ESRD were critically appraised, had relevant data extracted and were summarised narratively. A Markov (state transition) model was developed that compared cinacalcet in addition to current standard treatment with phosphate binders and vitamin D to standard treatment alone. A simulated cohort of 1000 people aged 55 with SHPT was modelled until the whole cohort was dead. Incremental costs and quality-adjusted life-years (QALYs) were calculated. Extensive one-way sensitivity analysis was undertaken as well as probabilistic sensitivity analysis.

RESULTS

Seven trials comparing cinacalcet plus standard treatment with placebo plus standard treatment were included in the systematic review. A total of 846 people were randomised to receive cinacalcet. Cinacalcet was more effective at meeting parathyroid hormone (PTH) target levels (40% vs 5% in placebo, p < 0.001). In those patients meeting PTH targets, 90% also experienced a reduction in calcium-phosphate product levels, compared with 1% in placebo. Significantly fewer people treated with cinacalcet were hospitalised for cardiovascular events, although no difference was seen in all-cause hospitalisation or mortality. Significantly fewer fractures and parathyroidectomies were also seen with cinacalcet. Findings on all patient-based clinical outcomes were based on small numbers. The authors' economic model estimated that, compared to standard treatment alone, cinacalcet in addition to standard care costs an additional 21,167 pounds and confers 0.34 QALYs (or 18 quality-adjusted weeks) per person. The incremental cost-effectiveness ratio (ICER) was 61,890 pounds/QALY. In most cases, even extreme adjustments to individual parameters did not result in an ICER below a willingness-to-pay threshold of 30,000 pounds/QALY with probabilistic analysis showing only 0.5% of simulations to be cost-effective at this threshold. Altering the assumptions in the model through using different data sources for the inputs produced a range of ICERs from 39,000 pounds to 92,000 pounds/QALY.

CONCLUSIONS

Cinacalcet in addition to standard care is more effective than placebo plus standard care at reducing PTH levels without compromising calcium levels. However, there is limited information about the impact of this reduction on patient-relevant clinical outcomes. Given the short follow-up in the trials, it is unclear how data should be extrapolated to the long term. Together with the high drug cost, this leads to cinacalcet being unlikely to be considered cost-effective. Recommendations for future research include obtaining accurate estimates of the multivariate relationship between biochemical disruption in SHPT and long-term clinical outcomes.

Insulin resistance plays a significant role in liver fibrosis in chronic hepatitis C and in the response to antiviral therapy

OBJECTIVES

To assess whether insulin resistance is associated with liver fibrosis in a group of patients with chronic hepatitis C virus (HCV) infection and whether there were any differences in insulin resistance between Asians and the indigenous Caucasian population. Secondly, to assess whether insulin resistance is associated with sustained virological response to antiviral therapy.

METHODS

We determined insulin resistance in 59 (30 Caucasians; 29 Asians) consecutive patients with HCV prior to starting antiviral therapy. Insulin resistance was measured using the homeostasis model assessment of insulin resistance (HOMA-IR). The relationship between insulin resistance and biochemical, virological, and histological data together with response to antiviral therapy was assessed.

RESULTS

In multivariable analyses, insulin resistance as measured using the HOMA-IR model correlated positively with the stage of fibrosis, with higher degrees of insulin resistance in those with greater degrees of fibrosis (p < 0.001). This significant relationship remained even after excluding cirrhotic patients, or after adjusting for other factors associated with fibrosis in univariable analyses. Insulin resistance was significantly higher in Asians than Caucasians (p= 0.004). Around half (55.6%) of patients completing a course of antiviral treatment had a sustained virological response. Multivariable logistic regression identified HCV genotype 3, lower fasting glucose levels, and lower aspartate transaminase (AST) levels as being associated with a higher odds of a sustained virological response. After adjusting for these variables, Asian ethnicity, higher fasting insulin levels, and higher HOMA-IR levels were all associated with a poorer virological response to therapy.

CONCLUSIONS

Insulin resistance contributes to liver fibrosis in chronic HCV infection; this relationship is not genotypic specific. Asian patients had higher insulin resistance than Caucasians. Insulin resistance is also an important predictor of sustained response to antiviral therapy.

An unusual form of autoimmune hepatitis in young Somalian men

BACKGROUND

Significant diversity in disease severity has been identified for autoimmune disorders among different ethnic groups. Current knowledge of both the natural history and management of autoimmune hepatitis (AIH) has been derived from European or Japanese patients, and there is limited information about the disease in patients from other ethnic groups.

AIMS

To assess the clinical, histological and immunological features of AIH in patients from Somalia and to determine their response to therapy.

METHODS

Retrospective review of a cohort of young Somalian men with atypical AIH compared with a control group of European patients.

RESULTS

The six Somalian men were younger at presentation (median age 37 (range 24-59) years) than the seven female and three male European controls (55 (34-54) years, P = 0.06). The Somalians had slightly more severe disease at presentation-median modified Ishak stage of 2.5 compared with 2 in Europeans (P = 0.61) and four (66%) had features of cholestasis compared with only one (10%) European patient (P = 0.04). Therapy with prednisolone and azathioprine was completely effective for eight of 10 Europeans but only one of seven Somalians (P = 0.04). Analysis of human leucocyte antigen types revealed differences between the Somalian and European patients, although these differences did not reach statistical significance.

CONCLUSIONS

Somalian men with AIH present with cholestatic features and respond poorly to standard immunosuppressive regimes.

Discontinuation of pegylated interferon plus ribavirin in patients who are not responding to therapy -- patients' views of early cessation of therapy

BACKGROUND

Current therapy for chronic hepatitis C infection involves a course of pegylated interferon and ribavirin. Patients who do not show a virological response after 12 weeks of therapy have a low probability of sustained virological response and it is therefore recommended that such patients stop treatment.

AIM

To assess patients' views of early treatment cessation.

METHODS

We conducted a open-labelled study in three UK centres, in which patients with biopsy-proven chronic hepatitis C requiring therapy were offered the choice of a full course of therapy with 40 kDa pegylated interferon-alpha 2a plus ribavirin (24 or 48 weeks depending on viral genotype) or early cessation if therapy had failed after 12 weeks.

RESULTS

Ninety-five participants were enrolled and the majority (69%) did not wish to discontinue therapy even if it had low probability of success. In this unselected UK population, very few patients (4%) did not achieve an early virological response with the 40-kDa pegylated interferon-alpha 2a plus ribavirin and two of the four early virological non-responders decided to continue therapy.

CONCLUSION

Early discontinuation of 'ineffective' anti-viral therapy may prove less popular with patients than with health care providers, and further patient-directed education regarding the cost-effectiveness of therapy will be needed if early discontinuation of unsuccessful therapy is to be accepted by patients.

Vitamin C for preventing and treating the common cold

BACKGROUND

The role of oral vitamin C (ascorbic acid) in the prevention and treatment of the common cold has been a subject of controversy for at least sixty years. Public interest in the topic continues to be high and vitamin C continues to be widely sold and used as a preventive and therapeutic agent for this common ailment.

OBJECTIVES

To discover whether oral vitamin C in doses of 200 mg or more daily, reduces the incidence, duration or severity of the common cold when used either as continuous prophylaxis or after the onset of cold symptoms.

SEARCH STRATEGY

This updated review added to earlier searches, a full search of the following electronic databases: the Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2004); MEDLINE (January 1966 to June 2004); and EMBASE (1990 to June 2004).

SELECTION CRITERIA

Papers were excluded if a dose less than 200 mg daily of vitamin C was used; if there was no placebo comparison; if methods of outcome assessment were inadequately described; and if the report did not record any of the three study outcomes (incidence, duration or severity) in sufficient detail to enter into the meta-analysis. Three criteria of study quality were assessed: Jadad scores, placebo distinguish-ability, and allocation concealment.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed trial quality. 'Incidence' of colds during prophylaxis was assessed as the proportion of participants experiencing one or more colds during the study period. 'Duration' was the mean days of illness of cold episodes and 'severity' of these episodes was assessed by days confined indoors, off work or school. or by symptom severity scores.

MAIN RESULTS

Twenty-nine trial comparisons involving 11,077 study participants contributed to the meta-analysis on the relative risk (RR) of developing a cold while taking prophylaxis. The pooled RR was 0.96 (95% CI 0.92 to 1.00). A subgroup of six trials that involved a total of 642 marathon runners, skiers, and soldiers on sub-arctic exercises reported a pooled RR of 0.50 (95%CI 0.38 to 0.66). Thirty comparisons that involved 9,676 respiratory episodes contributed to the meta-analysis on common cold duration during prophylaxis . A consistent benefit was observed, representing a reduction in cold duration of 8% (95% CI 3% to 13%) for adult participants and 13.5% (95% CI 5% to 21%) for child participants. Fifteen trial comparisons that involved 7,045 respiratory episodes contributed to the meta-analysis of severity of episodes experienced while on prophylaxis. The pooled results revealed a difference favouring those on vitamin C when days confined to home and off work or school were taken as a measure of severity (p = 0.02), and when restricting to studies which used symptom severity scores (p = 0.16), and for the both measures of severity combined (p = 0.004). Seven trial comparisons that involved 3,294 respiratory episodes contributed to the meta-analysis of cold duration during therapy with vitamin C that was initiated after the onset of cold symptoms, and no significant difference from placebo was seen. Four trial comparisons that involved 2,753 respiratory episodes, contributed to the meta-analysis of cold severity during therapy and no significant difference from placebo was seen.In laboratory studies, differing methods of artificial transmission of virus to vitamin C or placebo treated volunteers in residential experiments gave different results. Volunteers infected by nasal installation showed small or no benefit from vitamin C, whereas a group who were infected more naturally, reported less severe symptom severity scores (p = 0.04).

REVIEWERS' CONCLUSIONS

The failure of vitamin C supplementation to reduce the incidence of colds in the normal population indicates that routine mega-dose prophylaxis is not rationally justified for community use. But evidence shows that it could be justified in persons exposed to brief periods of severe physical exercise and/or cold environments. Also, the consistent and statistically significant small benefits on duration and severity for those using regular vitamin C prophylaxis indicates that vitamin C plays some role in respiratory defence mechanisms. The trials in which vitamin C was introduced at the onset of colds as therapy did not show any benefit in doses up to 4 grams daily, but one large trial reported equivocal benefit from an 8 gram therapeutic dose at onset of symptoms.

Vitamin A for treating measles in children

BACKGROUND

Measles is a leading cause of childhood morbidity and mortality. Vitamin A deficiency is a recognised risk factor for severe measles. The World Health Organization (WHO) recommends administration of an oral dose of 200,000 IU (or 100,000 IU in infants) of vitamin A per day for two days to children with measles in areas where vitamin A deficiency may be present.

OBJECTIVES

The purpose of this review is to determine whether vitamin A when commenced after measles has been diagnosed, is beneficial in preventing mortality, pneumonia and other complications in children.

SEARCH STRATEGY

MEDLINE and the Cochrane Library, Issue 4, 1999 were searched.

SELECTION CRITERIA

Only randomized controlled trials in which children with measles were given vitamin A or placebo along with standard treatment were considered.

DATA COLLECTION AND ANALYSIS

Studies were assessed independently by two reviewers. The analysis of dichotomous outcomes was done using the StatXact software package. Sub-group analyses were done for dose, formulation, age, hospitalisation and pneumonia specific mortality. Weighted mean difference with 95% CI were calculated for continuous outcomes.

MAIN RESULTS

The relative risks (RR) and 95% Confidence Intervals (CI) are based on the estimates from the StatXact software package. There was no significant reduction in mortality in the vitamin A group when all the studies were pooled together (RR 0.60; 95% CI 0.32 to 1.12)(StatXact estimate). There was a 64% reduction in the risk of mortality in children who were given two doses of 200,000 IU of vitamin A (RR=0.36; 95% CI 0.14 to 0.82) as compared to placebo. Two doses of water based vitamin A were associated with a 81% reduction in risk of mortality (RR=0.19; 95% CI 0.02 to 0.85) as compared to 48% seen in two doses of oil based preparation (RR=0.52; 95% CI 0.16 to 1.40). Two doses of oil and water based vitamin A were associated with a 82% reduction in the risk of mortality in children under the age of 2 years (RR=0.18; 95% CI 0.03 to 0.61) and a 67% reduction in the risk of pneumonia specific mortality (RR=0.33; 95% CI 0.08 to 0.92). There was no evidence that vitamin A in a single dose of 200,000 IU was associated with a reduced risk of mortality among children with measles (RR=0.77; 95% CI 0.34 to 1.78). Sub-groups like age, dose, formulation, hospitalisation and case fatality in the study area were highly correlated and there were not enough studies to separate out the individual effects of these factors. There was a 47% reduction in the incidence of croup (RR=0.53; 95% CI 0.29 to 0.89), while there was no significant reduction in the incidence of pneumonia (RR=0.92; 95% CI 0.69 to 1.22) or of diarrhoea (RR=0.80; 95% CI 0.27 to 2.34). Duration of diarrhoea was measured in days and there was a reduction in its duration of almost two days WMD -1.92, 95% CI -3.40 to -0.44. Only one study evaluated otitis media and found a 74% reduction in its incidence (RR=0.26, 95% CI, 0.05 to 0.92). We did not find evidence that a single dose of 200,000 IU of vitamin A per day, given in oil-based formulation in areas with low case fatality, was associated with reduced mortality among children with measles. However, there was evidence that the same dose given for two days was associated with a reduced risk of overall mortality and pneumonia specific mortality.

REVIEWER'S CONCLUSIONS

Although we did not find evidence that a single dose of 200,000 IU of vitamin A per day was associated with reduced mortality among children with measles, there was evidence that the same dose given for two days was associated with a reduced risk of overall mortality and pneumonia specific mortality. The effect was greater in children under the age of two years. There were no trials that compared a single dose with two doses, although the precision of the estimates of trials that used a single dose were similar to the trials that used two doses.

Lessons to be learned: a case study approach a case study of the temporal onset of pulmonary hypertension with pre-existent cirrhotic portal hypertension

We report the occurrence of pulmonary hypertension in a 37-year-old male patient with cirrhosis of the liver, portal hypertension and oesophageal varices. Although this is a rare combination, previous reports have shown that the association of portal and pulmonary hypertension is not coincidental; the temporal onset of primary pulmonary hypertension is hard to predict and our patient was asymptomatic for a number of years. The pathogenesis of portal hypertension leading to pulmonary hypertension is not known. Diagnosis is difficult because the clinico-pathological symptoms in both conditions are similar. Treatment is limited to calcium channel blockers, vasodilators, nitrous oxide and prostacyclin, although most patients will eventually require visceral transplantation.

Experience of a small British pacing centre between 1994 and 2000: some answers to the problem of low UK implantation rates

Raigmore is a district general hospital offering a permanent pacemaker service to its catchment population of 233,500. This report reviews the pacemaker practice over a seven year period (1994 to 2000) and makes a comparison with the national database and other hospitals in the UK. The records of all patients receiving new implantions for the period under observation were reviewed retrospectively. Data collected included number of patients paced each year, age, sex, indications and complications. In the 84 months studied 3/71 patients received new permanent pacemakers (the mean age was 74 years and 51% were male). The most common presenting symptoms were syncope (62%), dizzy spells (24%), and heart failure (11.5%). The most common indication for permanent pacemaker insertion was complete atrioventricular block (58%) followed by sick sinus syndrome (20%). The implantation rate was 419.3/million population/year in 2000. Pacemaker modes used were appropriate and the early and late complication rates were low (2.7%). This current audit demonstrates continued growth of the service with low-complication rates and implantation rates which approach those in Western Europe and North America.

Neurogenic pulmonary oedema induced by bacterial meningitis: a case report

We report a case of neurogenic pulmonary oedema occurring in association with bacterial meningitis. An 87 year old man suddenly developed severe dyspnoea without cardiac failure (MUGA scan ejection fraction 47%). Radiographs showed pulmonary oedema. A few hours later he developed signs of meningitis and lumbar puncture suggested a partially treated bacterial meningitis. We suspect that the bacterial meningitis had induced neurogenic pulmonary oedema.

Pharmacokinetic study of niosome encapsulated insulin

Pharmacokinetic profile and hypoglycemic effect, after intraperitoneal injection of insulin and insulin encapsulated in niosomes were determined in diabetic rats. Niosomes (non-ionic surfactant vesicles) of different doses and different lipid compositions were prepared by lipid layer hydration method. Plasma samples were collected at specified time intervals and plasma concentration of insulin was determined by HPLC. Blood glucose level was estimated spectrophotometrically using commercial glucose assay kit. In vitro release and pharmacokinetic profile of niosomal formulation and free insulin were evaluated. Though there was a slight delay in the in vitro drug release due to cholesterol content in the niosomes, there was no difference between the two preparations when plasma levels were compared in vivo. Niosomes significantly reduced the blood glucose level in diabetic rats. Fall in blood glucose level was almost 92% of initial value. In case of the niosomal form the half-life of insulin was prolonged by 4 -5 hr in contrast to 2 hr for free drug. Niosomes maintained the plasma insulin level up to 12 hr, but free drug was cleared quickly. The area under the plasma concentration-time curve for niosomal forms was, 26.07 degrees +/- 0.99 mIU. hr/ml and for free insulin was 11.722 +/- 1.00 mIU. hr/ml. More than 80% of the drug was successfully encapsulated to give a formulation with sustained release characteristics. Entrapment efficiency increased with increasing lipid concentration and decreased with increasing drug concentration. The results showed that insulin entrapped in niosomes prolongs the existence of drug in the body therefore increasing its therapeutic value.

Telemedicine for intensive support of psychiatric inpatients admitted to local hospitals

A service was developed to treat acute psychiatric inpatients in their local hospitals using telemedicine. This reduced the need for these patients to be transferred to a psychiatric facility in Adelaide. An evaluation of outcomes showed that it was possible to manage acute psychiatric patients in this manner, reducing costs of transport. In addition, patients were treated close to their homes. Patients rated their satisfaction with the service and the use of telemedicine very highly.

A pilot study of an educational service for rural mental health practitioners in South Australia using telemedicine

Studies have found that rural patients want to be treated in their local hospitals. However, there have been difficulties with recruiting and retaining professionals in rural areas of Australia. Isolation, lack of professional development programmes, lack of academic programmes, lack of peer consultation and the need to travel long distances are some of the reasons identified in the National Rural Health strategy. A pilot service of educational programmes delivered by telemedicine was initiated and then evaluated. Forty-six community mental health workers from nine rural areas and 20 general practitioners from five rural areas participated. High satisfaction with the use of telemedicine was recorded by both groups. Telemedicine reduced the disincentives to rural practice, and also improved the professionals' competence and confidence in managing patients with psychiatric illness.

Antibiotics for preventing pneumonia in children with measles

BACKGROUND

Measles causes more than a million deaths a year, of which most are children under five years of age who die from pneumonia.

OBJECTIVES

The objective of this review was to assess the effects of antibiotics given to children with measles on reducing pneumonia or mortality, and to assess whether antibiotics should be given to all children with measles in communities with a high fatality rate.

SEARCH STRATEGY

We searched MEDLINE (1966 - 1999), EMBASE (1980-1999) and the specialized trials register of the Acute Respiratory Infections Group in August 1999, and all relevant journals in the University of Melbourne medical library for the years 1935-46.

SELECTION CRITERIA

Randomised or controlled trials of antibiotics for children with measles.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed trial quality.

MAIN RESULTS

Six trials with 1304 children were included. All but one of the trials were unblinded, and randomisation was either not described or was by alternate allocation. In four studies, the incidence of pneumonia in the control group was similar to that in the antibiotic prophylaxis group; in the other two studies, the incidence of pneumonia was unusually high in the control group so these children had a higher complication rate than the antibiotic group. Four of the 764 children given antibiotics died compared with one of the 637 controls.

REVIEWER'S CONCLUSIONS

The quality of the trials reviewed was poor, and they provide very weak evidence for giving antibiotics to all children with measles. Available evidence suggests that antibiotics should be given only if a child has clinical signs of pneumonia or other evidence of sepsis.

Australia's notifiable diseases status, 1997. Annual report of the National Notifiable Diseases Surveillance System

In 1997 there were 89,579 notifications to the National Notifiable Diseases Surveillance System. A notable feature of 1997 was the pertussis outbreak which peaked towards the end of the year and resulted in 10,668 cases being notified. The highest number of notifications received was for hepatitis C (unspecified) with 19,692 notifications; this is the first year for which data have been reported for New South Wales and South Australia for this disease category. The number of measles cases rose after the low number reported in 1996 but is still well below the number reported in the outbreak years of 1993 and 1994. Rubella notifications continued to decline in 1997. Notifications of Haemophilus influenzae type b appeared to have stabilised at a low rate, having declined markedly after introduction of the conjugated vaccine in 1992. The number of cases of campylobacteriosis remained steady after having risen for several years. Notifications of hepatitis A cases rose considerably, much of this being due to one outbreak in New South Wales. The number of cases of salmonellosis rose while shigellosis numbers dropped slightly. Notifications for chlamydial infection and gonococcal infection continued to rise, whilst those for syphilis continued to fall.

Periapical inflammatory responses and their modulation

Periapical inflammatory responses occur as a consequence of bacterial infection of the dental pulp, as a result of caries, trauma, or iatrogenic insult. Periapical inflammation stimulates the formation of granulomas and cysts, with the destruction of bone. These inflammatory responses are complex and consist of diverse elements. Immediate-type responses--including vasodilatation, increased vascular permeability, and leukocyte extravasation--are mediated by endogenous mediators, including prostanoids, kinins, and neuropeptides. Non-specific immune responses--including polymorphonuclear leukocyte and monocyte migration and activation, and cytokine production--are elicited in response to bacteria and their products. Interleukin-1 and prostaglandins in particular have been implicated as central mediators of periapical bone resorption. Chronic periapical inflammation further involves specific T- and B-cell-mediated anti-bacterial responses, and activates a network of regulatory cytokines which are produced by Th1- and Th2-type T-lymphocytes. Various naturally occurring and genetically engineered models of immunodeficiency are beginning to help elucidate those components of the immune system which protect the pulpal/periapical complex. Both specific and non-specific responses interface with and are regulated by the neural system. The modulation of these responses by immune response modifies, cytokine antagonists, and other novel therapeutic agents is discussed. As an experimental model, periapical inflammation has many advantages which permit it to be used in studies of microbial ecology and pathogenesis, host response, neuroimmunology, and bone resorption and regeneration.

Australia's notifiable diseases status, 1996. Annual report of the National Notifiable Diseases Surveillance System

In 1996 there were 65,024 notifications to the National Notifiable Diseases Surveillance System. The record high number of Ross River virus infection notifications was of particular note. The highest rates were recorded in Western Australia, where an outbreak was documented in the South West, and in Queensland. Most cases occurred in the late summer and early autumn months. The number of measles cases has continued to fall markedly following the outbreak in 1993 and 1994. Rubella notifications also fell in 1996. The number of cases of pertussis remained at a similar level to that recorded in recent years, the highest notification rate being recorded for children under the age of one year. A peak in late 1996 marked a resurgence in the pertussis epidemic which has continued into 1997. Notifications of Haemophilus influenzae type b continued to decline reaching a record low rate of 0.3 notifications per 100,000 population. For the enteric diseases, the number of cases of campylobacteriosis rose, with an annual adjusted notification rate of 100.4 per 100,000 population; more notifications were received for this disease than for any other in 1996. The number of hepatitis A cases also rose relative to 1995. This is a reversal of the trend observed in recent years when the notification rate fell. The number of cases of salmonellosis and shigellosis remained stable. Notifications for chlamydial infection and gonococcal infection rose relative to 1995, whilst those for syphilis fell.

Antibiotic prophylaxis in patients undergoing radiological procedures who are at risk of infective endocarditis--do radiologists know what they are doing?

The British Society for Antimicrobial Chemotherapy has published guidelines recommending that all patients with prosthetic heart valves, or those with a previous history of bacterial endocarditis, should receive prophylactic antibiotics before procedures likely to cause a bacteraemia, due to the potential risk of bacterial endocarditis. The guidelines are widely available, notably in the British National Formulary. Two separate and independent surveys of radiologists in this Region showed that there was poor awareness of these guidelines and their implications for radiology departments.

Coordinate patterns of expression of type I and III collagens during mouse development

The extracellular proteins types I and III collagen are abundantly expressed during development. Here, the patterns of the pro alpha 1(I), pro alpha 2(I), and pro alpha 1(III) collagen mRNAs are systematically examined from 7.5 to 17.5 days of development (E7.5 to E17.5) in the mouse using in situ hybridization with specific riboprobes. Coordinated expression of pro alpha 1(I) and pro alpha 2(I) collagen mRNA was found throughout development in all regions examined. Widespread type I collagen expression starting at E8.5 occurred in embryonic mesoderm, sclerotomes, dermatomes, and in the forming connective tissues. After E14.5, regions of ossification showed highest levels of type I collagen expression. Pro alpha 1(III) collagen expression was specific to and coordinated with patterns of type I collagen expression in many fibroblast-containing tissues. No expression of type III collagen occurred in osteoblasts. This comprehensive study of the transcripts of abundantly expressed structural proteins should provide a basis for comparison of other key extracellular matrix molecules and serve as a reference for studies on the patterns of activities of various promoter/enhancer-reporter gene constructions of type I and III collagen genes in transgenic mice.

The matrix Gla protein gene is a marker of the chondrogenesis cell lineage during mouse development

Matrix Gla protein (MGP) is, along with osteocalcin, a skeletal member of the family of extracellular mineral-binding Gla proteins. Although the precise function of these proteins remains obscure, circumstantial evidence suggests that they play a role in endochondral ossification. As a first step toward understanding MGP function we have performed a preliminary characterization of its promoter element and studied the developmental pattern of expression of this gene. DNA transfection experiments indicate that the mouse MGP promoter functions better in cells expressing the MGP gene than in cells that do not express the gene. During mouse development, MGP gene expression is detectable as early as day 10.5 of embryonic development (E10.5), before any skeletal structures are identifiable. In situ hybridization analysis shows that MGP mRNA is initially present at the mesenchymal epithelial interphase in lung and limb buds. As development proceeds, MGP gene is predominantly expressed in cells of the chondrocytic lineage in areas that will undergo endochondral ossification as well as in areas that will remain cartilaginous, such as the trachea and bronchi. In growth plate cartilage, MGP mRNA is present in resting, proliferative, and late hypertrophic chondrocytes. Surprisingly, MGP mRNA is absent from the early hypertrophic chondrocytes and from the osteoblasts. Finally, the MGP gene is expressed at a lower level in kidney medulla and uterus smooth muscle but not in brain, spleen, or heart during development. This study demonstrates that during development MGP gene expression occurs early and is predominant at the epithelial mesenchymal interfaces, principally of lung and limb buds, and in cells of the chondrocytic lineage. This finding raises the intriguing possibility that MGP may play distinct roles during embryogenesis and in the adult organism.

A developing country's university oriented toward strengthening health systems: challenges and results

OBJECTIVES

The Aga Khan University in Karachi has a mission to educate leaders and to contribute to the development of health systems for Pakistan amid challenges of scarcity and complexity.

METHODS

Its key activities are (1) to design and test urban and rural health system prototypes, (2) to develop faculty in medical and nursing postgraduate community health sciences programs, and (3) to design and implement community-based undergraduate medical and nursing curricula.

RESULTS

The university has developed equity-based, cost-effective primary health care prototypes in Karachi slums. With government counterparts it has tested village-, facility-, and district-level interventions in a poor rural district. Federal policymakers have taken models from each for widespread replication. The university is training 49 medical and 19 nursing faculty for postgraduate programs in community health sciences. Most faculty retain institutional leadership positions, including teaching community-based, problem-solving, community health sciences as 20% of the medical and nursing undergraduate curriculum.

CONCLUSIONS

The mission and experience of the Aga Khan University in population-based health systems design and health sciences education can guide universities in both developing and developed countries.

Glomerular injury induced by hydrogen peroxide: modifying influence of ACE inhibitors

The sensitivity of isolated glomeruli from normotensive (Wistar-Kyoto, WKY) and spontaneously hypertensive (SHR) strains to oxidant stress was studied by determining the incidence of pyknosis, karyohexis and karyolysis after incubation with different concentrations of hydrogen peroxide (H2O2) (4.7 x 10(-9) - 10(-3) M). Even though the proportion of glomeruli containing nuclei that demonstrated these features increased progressively with increasing concentrations of H2O2, the number of severely damaged glomeruli was relatively small even at concentrations of 4.7 x 10(-3) M. Examination of the surface epithelial cells of glomeruli using scanning electron microscopy revealed no evidence of disturbance of the macroscopic or podocyte structure or, of increased blebbing after H2O2-treatment. These data suggest damage to nuclei is an early result of ROS stress on glomeruli. Preincubation of WKY glomeruli with captopril or lisinopril resulted in a significant drop in the proportion of WKY glomeruli demonstrating structural damage after oxidant stress. In contrast, preincubation of SHR glomeruli with lisinopril had no effect on oxidant-induced changes in the morphology of SHR glomeruli, whereas captopril effected a significant increase in the proportion of glomeruli demonstrating damage at all concentration of H2O2.

Detection and characterization of interleukin-1 in human dental pulps

Pulp tissue was obtained from clinically intact third molars and premolars, and from teeth affected by caries and periodontal disease. After incubation and homogenization, supernatants were centrifuged, sampled and assayed for lymphocyte activating factor-like activity using the thymidine-incorporated D10.G4.1 cell-line assay. Significantly higher levels of mitogenic activity were found in the pulp supernatants of symptomatic carious teeth, and in those of third molars with attendant pericoronitis, than in pulps from symptomatic and asymptomatic periodontally affected teeth and asymptomatic third molars and premolars. As both interleukin-1 (IL-1) and interleukin-2 (IL-2) may be involved in the proliferation of D10.G4.1 cells, supernatants from carious pulps were further tested for IL-2 activity using murine natural killer (NK) cells. Those that had elicited a proliferative response of D10.G4.1 cells did not enhance NK proliferation, indicating that the factor responsible for clonal replication of D10.G4.1 cells was IL-1. To confirm the presence of IL-1, immunohistochemistry using a monoclonal antibody to IL-1 was performed on frozen and paraffin-embedded sections of pulps from each group. IL-1 was immunolocalized within cells in pulps from the caries symptomatic group. The cell type producing IL-1 was further characterized as an alpha-naphthyl-acetate-esterase-positive macrophage within the connective tissue stroma of pulps from the caries symptomatic group. This novel demonstration of IL-1 and IL-1 producing cells in human dental pulp indicates the involvement of this mediator of inflammation in dental disease.