Long-term effectiveness of transforaminal anterolateral approach CT-guided cervical epidural steroid injections for cervical radiculopathy treatment

AIM

To evaluate the long-term clinical effectiveness of computed tomography (CT)-guided transforaminal cervical epidural steroid injection using an anterolateral approach for the treatment of cervical radiculopathy (CR) using well-established robust clinical scoring systems for neck pain and neck disability. Despite its widespread use, evidence to support the long-term benefit of routine cervical epidural steroid injection is currently very limited.

MATERIALS AND METHODS

This study included 113 patients with magnetic resonance imaging (MRI)-confirmed CR who underwent a steroid injection at a single cervical level via a unilateral transforaminal anterolateral approach. Pain was assessed quantitatively at pre-injection, 15 minutes post-injection, 1 month, 3 months, and at 1 year. Neck disability was assessed using the Oswestry Neck Disability Index (NDI) at pre-injection, 1 month, 3 months, and 1 year time points.

RESULTS

Eighty patients completed the study. Sixty per cent reported reduced neck pain (mean pain reduction, 55%), which was clinically significant in 45% cases. Furthermore, 66% reported an improvement in neck disability (mean improvement, 51%), which was clinically significant for 56% patients. Clinically significant good outcomes in both neck pain and neck disability were evident from as early as 1-month, and importantly, were independent both of pre-treatment CR characteristics (including severity of pre-injection neck pain or disability) and of findings on pre-injection MRI imaging.

CONCLUSION

Transforaminal anterolateral approach CT-guided epidural steroid injection resulted in a clinically significant long-term improvement in both neck pain and disability for half of the present cohort of patients with unilateral single-level CR. This improvement was independent of the severity of the initial symptoms and pre-injection MRI findings.

Development of a multiagency protocol to support people with No Recourse to Public Funds in Wolverhampton (UK)

BACKGROUND

No Recourse to Public Funds (NRPF) status is applied to individuals and families that are subject to immigration control, resulting in them having restricted access to state-funded benefits within England. NRPF is a public health risk as it increases the risk of destitution among vulnerable migrants.

AIMS

The aim of this study was to engage with public and voluntary sector staff within Wolverhampton working with people with a NRPF status to develop and create an easily accessible guide ('protocol') to help facilitate identification of appropriate cross-sector interventions and support.

METHODS

Data were collected via an online survey as well as face-to-face semi-structured interviews with local NRPF stakeholders.

RESULTS

Four themes emerged from the thematic analysis of participant responses: understanding NRPF statuses, varying support requirements, poor communication and awareness of vulnerabilities. Currently, in England, there does not appear to be a standardised localised protocol which can be used to reduce the complexities and confusion encountered by public and voluntary sectors who support people with NRPF status.

CONCLUSION

The findings from this study have allowed the Wolverhampton NRPF to create an online information resource that includes training events to raise the awareness of NRPF, as well as the development of a localised multiagency protocol that has better equipped it to support and safeguard people with NRPF.

"Those Who Need It the Most": Equity Framing in 2021 U.S. Print News About Food Assistance

Objective

To understand how equity appeared in news about food assistance from 2021.

Methods

We assessed a national sample of news articles (N=298) for equity arguments and language about racial and health equity.

Results

Only 28% of coverage argued that food assistance programs promote equity. Just 6% mentioned people of color or named racial disparities in food access.

Discussion

Narratives that explain how food assistance programs reduce inequities could deepen their policy appeal and broaden public perceptions around recipients.

Health Equity Implications

There are opportunities for news coverage to expand the discussion of how food assistance programs improve racial and health equity outcomes.

Ficus Benjamin's leaf, a native sorbent for the exclusion of Methyl violet 10B from aquatic media

Due to the use of non-recyclable materials and the high costs of the technologies, removal of dyes from wastewater is becoming more and more pricey. This paper presents the capacity of Ficus Benjamina (FB) leaf powder to eradicate methyl violet dye 10 B (MV) in an aqueous fluid. The surface characteristics and presence of various functional groups on the surface of sorbent were revealed by SEM and FTIR studies. Diverse constraints on the elimination of methyl violet 10 B in an aqueous environment were also studied, including starting dye concentration, temperature, and contact duration. The Elovich & liquid film diffusion models, along with Lagergren first-order, pseudo-second-order, Bangham, and modified Freundlich modeling operated to assess kinetics. Experiments confirmed the pseudo-second-order concept. To investigate tentative data, multiple linear Langmuir, Freundlich, Temkin, as well as two parameters nonlinear isotherm models were applied, with findings indicating that sorption data were like both linear and non-linear isotherms. Sorption data were found to be in excellent agreement with the Freundlich isotherm with R² value (0.99). The sorption capacity of the sorbent was computed i.e. 312.2 mg/g. Thermodynamic characteristics were also computed. It was concluded that the sorption of methyl violet 10 B sorption on FB leaf powder is exothermic. Hence, it is a potentially cost-effective bio sorbent for exclusion of dye from wastewater.

“People Like Us”: News Coverage of Food Assistance During the COVID-19 Pandemic

Objective:

Methods:

Results:

Discussion:

Health Equity Implications:

A Case-Control Study on Risk Predictors Associated with Periodontitis in Systemically Healthy Patients; a Regression Analysis

Aim: This case-control study was conducted to analyze the association of periodontitis with risk predictors i.e. age, gender, education status, brushing habits and past dental visits in systemically healthy patients. Materials and Methods: The study included total of 1097 systemically healthy, non-tobacco using patients with age ≥ 18 years that reported to periodontology department from year 2018. The demographic details and dental care pattern of the patients were extracted from the records of periodontology department, and their frequencies were formulated. The association of five study variables i.e. age, gender, education status, brushing habits and past dental visits was assessed using forward step-wise logistic regression analysis. Results: Total of 471(42.9%) patients were diagnosed with periodontitis. Higher frequency of periodontitis was observed in patients who were male and ≥ 50 years of age. Regression analysis showed that the subjects with < 50 years of age, ≥ 12 years of education, regular brushing habits and regular past dental visits had greater odds of being safe from periodontitis. Conclusion: Since the population chosen for this research was systemically healthy, non-tobacco using individuals, a high prevalence (42.9%) of periodontitis was observed indicating the need to analyze the factors other than systemic conditions contributing in prevalence of periodontitis. Furthermore, a positive association between study variables and periodontitis was observed in this research, which will help the clinicians in prediction of periodontitis in systemically healthy, non-tobacco using individuals.

Frequency of Musculoskeletal Disorders and their Counter Measures Adopted by Final Year Students and Young Dentists: A Questionnaire Based Multicenter Study

Aim: Musculoskeletal disorders have significantly been related to poor ergonomics practice during clinics. There is limited data regarding the prevalence and reasons for work-related musculoskeletal disorders in young dentists. This study was conducted to find out the prevalence of musculoskeletal disorders in young dentists, identification of the perceived reasons for musculoskeletal disorders, and measures taken to manage them. Study Design: Cross-sectional observational study. Methods: A cross-sectional study was conducted on 408 house officers from ten dental institutes of twin cities and Karachi, Pakistan. The subjects were inquired through a validated questionnaire about the presence of muscular pain, affected body regions, frequency, intensity, nature of onset, aggravating factors, and average duration of the pain episodes. They were also asked about measures taken to counter musculoskeletal pain and their effectiveness. Results: The overall prevalence of musculoskeletal disorders was n=231(56.6%) with n=172(39.2%) of participants reporting it to be work-related with a higher percentage of females n=138/172 (80.2%) The most affected body regions were the back n=101/172 (58.7%), shoulders n=91/172 (52.9%) and neck n=80/172(46.5%). Improper posture n=108(62.8%) followed by prolonged sitting n=88(51.2%) were the most common reasons perceived by the young dentists for their pain. Bed rest was adopted 93(54.1%) to alleviate pain followed by posture rectification 76(44.2%). Most n=134(77.9%) of them thought that these measures are helpful for the alleviation of pain. Conclusion: The prevalence of work-related musculoskeletal disorders among young dentists is high. The back, shoulder, and neck areas were more frequently affected. A higher percentage of females suffered from MSD as compared to males. Bed rest was the most common measure adopted to alleviate the pain. Very few of them sought professional help for their musculoskeletal disorders.

Clinicopathological spectrum of Diffuse Large B Cell lymphoma: a study targeting population yet unexplored in Pakistan

Objective

Diffuse Large B Cell Lymphoma (DLBCL) is the most common type of Non-Hodgkin Lymphoma (NHL). The aim of this study was to assess the clinico pathological characteristics of DLBCL specifically, among the affected individuals residing in Northern areas of Pakistan who had not been previously included in major lymphoma studies due to their remote location.

Results

Mean age of the patients was 49.7 years. Male: female ratio was 1.5:1. Primary site was lymph node in 99 (71.74%) patients, out of which, 36 (26.09%) patients had B symptoms and 19 (13.77%) patients had stage IV disease. 39 (28.26%) patients had primary extra nodal involvement, 4 (2.90%) patients had B symptoms and 3 (2.17%) had stage IV disease. Extra nodal sites involved in primary extra nodal DLBCL were gastrointestinal tract (GIT) 19 (48.72%), tonsils 6 (15.38%), spine 4 (10.26%), soft tissue swelling 3 (7.69%), parotid gland 2 (5.13%), thyroid 2 (5.13%) central nervous system (CNS) 1 (2.56), breast 1 (2.56%) and bone marrow 1 (2.56%). Our study revealed increased percentage of patients with nodal DLBCL in stage IV and with B symptoms. Few patients with primary extra nodal DLBCL had B symptoms and stage IV disease at presentation. GIT was the most common site of involvement in primary extra nodal DLBCL.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-021-05768-5.

O32: TRANSPARENCY IN SURGICAL RANDOMISED CONTROLLED TRIALS: CROSS-SECTIONAL, OBSERVATIONAL STUDY

Introduction

Randomised controlled trials (RCT) often provide the scientific basis on which commissioning and treatment decisions are made. It is essential that their results and methods are reported transparently. The aim of this study was to explore transparency with respect to trial registration, disclosure of funding sources, conflicts of interest (COI), and data sharing.

Method

This was a cross-sectional review of surgical RCTs. Data were extracted from RCTs in ten high-impact journals published in the years 2009, 2012, 2015, and 2018. Outcomes of interest were the incidence of reported trial registration, disclosure of funding sources, disclosure of investigator COI, and presence of a statement of data sharing plans.

Result

A total of 475 were eligible for analysis. Trial registration was present in 73 (67%) studies in 2009, 137 (84%) in 2012, 111 (89%) in 2015 and 110 (93%) in 2018. Funding statements were provided in 55%, 65%, 69.4%, and 75.4% of manuscripts, respectively. Conflicts of interest statements were provided in 49.5%, 89.1%, 94.6%, and 98.3% of manuscripts, respectively. Data sharing statements were present in only 15 (3.2%) RCTs. Eleven of these were in studies published most recently in 2018.

Conclusion

Trial registration, presence of funding statements, and disclosure of personal conflicts of interest in surgical RCTs have improved rapidly over the last 10 years. In contrast, disclosure of data sharing plans is exceptionally low. This may contribute to research waste and represents an essential target for improvement.

Take-home message

Trial registration, presence of funding statements, and disclosure of personal conflicts of interest in surgical RCTs have improved rapidly over the last 10 years. In contrast, disclosure of data sharing plans is exceptionally low. This may contribute to research waste and represents an essential target for improvement.

Transparency in surgical randomized clinical trials: cross-sectional observational study

BACKGROUND

RCTs provide the scientific basis upon which treatment decisions are made. To facilitate critical review, it is important that methods and results are reported transparently. The aim of this study was to explore transparency in surgical RCTs with respect to trial registration, disclosure of funding sources, declarations of investigator conflicts and data-sharing.

METHODS

This was a cross-sectional review of published surgical RCTs. Ten high-impact journals were searched systematically for RCTs published in years 2009, 2012, 2015 and 2018. Four domains of transparency were explored: trial registration, disclosure of funding, disclosure of investigator conflicts, and a statement relating to data-sharing.

RESULTS

Of 611 RCTs, 475 were eligible for analysis. Some 397 RCTs (83.6 per cent) were registered on a trial database, of which 190 (47·9 per cent) had been registered prospectively. Prospective registration increased over time (26 per cent in 2009, 33·0 per cent in 2012, 54 per cent in 2015, and 72·7 per cent in 2018). Funding disclosure was present in 55·0, 65·0, 69·4 and 75·4 per cent of manuscripts respectively. Conflict of interest disclosure was present in 49·5, 89·1, 94·6 and 98·3 per cent of manuscripts across the same time periods. Data-sharing statements were present in only 15 RCTs (3·2 per cent), 11 of which were published in 2018.

CONCLUSION

Trial registration, disclosure of funding and disclosure of investigator conflicts in surgical RCTs have improved markedly over the past 10 years. Disclosure of data-sharing plans is exceptionally low. This may contribute to research waste and represents a target for improvement.

Use of artificial intelligence in diagnosis of head and neck precancerous and cancerous lesions: A systematic review

This systematic review analyses and describes the application and diagnostic accuracy of Artificial Intelligence (AI) methods used for detection and grading of potentially malignant (pre-cancerous) and cancerous head and neck lesions using whole slide images (WSI) of human tissue slides. Electronic databases MEDLINE via OVID, Scopus and Web of Science were searched between October 2009 - April 2020. Tailored search-strings were developed using database-specific terms. Studies were selected using a strict inclusion criterion following PRISMA Guidelines. Risk of bias assessment was conducted using a tailored QUADAS-2 tool. Out of 315 records, 11 fulfilled the inclusion criteria. AI-based methods were employed for analysis of specific histological features for oral epithelial dysplasia (n = 1), oral submucous fibrosis (n = 5), oral squamous cell carcinoma (n = 4) and oropharyngeal squamous cell carcinoma (n = 1). A combination of heuristics, supervised and unsupervised learning methods were employed, including more than 10 different classification and segmentation techniques. Most studies used uni-centric datasets (range 40-270 images) comprising small sub-images within WSI with accuracy between 79 and 100%. This review provides early evidence to support the potential application of supervised machine learning methods as a diagnostic aid for some oral potentially malignant and malignant lesions; however, there is a paucity of evidence using AI for diagnosis of other head and neck pathologies. Overall, the quality of evidence is low, with most studies showing a high risk of bias which is likely to have overestimated accuracy rates. This review highlights the need for development of state-of-the-art deep learning techniques in future head and neck research.

mHealth for Pneumonia Prevention

Introduction

Pneumonia contributes to 14% of under-five mortality in Pakistan. Delayed care seeking is one of the causes of death due to this disease. One of the most impactful strategies can be timely healthcare-seeking through CHW's. We, therefore propose to develop an intervention package for educating caregivers on pneumonia by Lady Health Workers (LHWs).

Methodology

This first phase of the feasibility study comprised of a systematic review (SR) on best mobile health-based approaches for CHWs on the management of childhood illness followed by formative research (FR). In the systematic review, 6 databases were searched, and 22 articles were included. Based on findings of SR and FR along with guidelines of WHO and UNICEF, a mobile application-based intervention package will be developed in the second phase. Recruited LHWs will use the mobile application in their monthly visits for 6 months. Text and voice messages will be sent to each caregiver. Pre and Post-intervention surveys will be conducted with the recruited caregivers to assess the impact of the intervention and FGDs with the recruited LHWs to get feedback on the intervention.

Findings

Findings of the systematic review suggest that the most common approaches of mobile health for community health workers is the use of a customized application for disease management and data collection. Findings of formative research suggest that the majority of the caregivers were not aware of the danger signs of pneumonia. Respondents agreed to the importance of an educational intervention package on pneumonia and its prevention by LHWs through mHealth.

Acknowledgment

This research was commissioned by the National Institute of Health Research using Official Development Assistance (ODA) funding. The views expressed in this publication are those of author(s) and not necessarily those of NHS, the National Institute of Health Research, or the development of Health.

Key messages

mHealth intervention employing community health workers can be a useful mode of improving healthcare services. Use of technology to raise awareness and delivered health-related information at community level can prove tremendously helpful for illness management.

To document Pneumonia case management practices in selected communities of Pakistan

Introduction

The cornerstone of ARI control programs is standardized case management. According to this strategy thousands of healthcare providers have been trained in Pakistan. Given unchanged mortality statistics, there is a concern that these pieces of training have not been able to deliver the outcome.

Purpose of Study

To document current under-five pneumonia case management practices at the community level, first level care facility (FLCF) and specialist level across Pakistan.

Methodology

32 structured; disguised observations were done using an observation tool based on standard WHO pneumonia case management guidelines from each of four administrative units and the federal capital of Pakistan across the LHW level, FLCF and tertiary level. Thus, a total of 160 observations were made.

Results

At the community level, 100% LHW's did not ask for danger signs & did not expose the chest, 98% misdiagnosed pneumonia and100% prescribed antibiotics to irrespective of diagnosis. At FLCF 0.6% inquired about danger signs, 98% did not expose the chest, 80% did not use WHO classification for diagnosing pneumonia and 100% prescribed antibiotics irrespective of diagnosis. At GP's and specialist level in the private sector, 28 % inquired about at least one danger sign, 82% exposed chest, 58% did not use WHO classification for diagnosis, and 17% wrongly prescribed antibiotics. Whereas in public sector, 7% inquired about at least one danger sign, 78% exposed chest, 64% did not use WHO classification for diagnosis and 28% wrongly prescribed antibiotics.

Acknowledgment of Funding

This research was commissioned by the National Institute of Health Research using Official Development Assistance (ODA) funding. The views expressed in this publication are those of the author(s) and not necessarily those of NHS, the National Institute of Health Research, or the development of Health.

Key messages

Standard pneumonia case management guidelines are not been followed at any level of healthcare systems in Pakistan. Pneumonia case management strategies need to be revised to manage the disease.

The role, efficacy and outcome measures for teriparatide use in the management of medication-related osteonecrosis of the jaw

Medication-related osteonecrosis of the jaw (MRONJ) is a complex disease which can be associated with multiple morbidities and is challenging to treat. This review evaluates the literature on the role and efficacy of teriparatide (TPTD) as a treatment for MRONJ. The clinical, radiological, histopathological and serological parameters used to assess treatment response have been described. Electronic databases were searched to retrieve articles (April 2005 and April 2020) based on strict inclusion criteria. Seventeen articles were included in this review. Of the 91 patients treated; only six received TPTD as a standalone treatment. There were significant variations in defining treatment outcomes and measuring treatment response. The longest follow-up period was 26 months, and 12 studies failed to report follow-up. The overall quality of evidence is weak with potential for a high risk of bias, making it difficult to determine the efficacy of TPTD and its long-term effects. However, TPTD may play a role in the treatment of intractable MRONJ in osteoporotic patients or those unfit for surgery. Therefore, randomized clinical trials on larger patient cohorts with long-term follow-up is required to confirm efficacy, safety and inform treatment indications for TPTD in the treatment of MRONJ.

Retailer perspectives on sugar-sweetened beverage taxes in the California Bay Area

The sugar-sweetened beverage (SSB) industry has claimed that food and beverage retailers are opposed to SSB taxes. In 2018 and 2019, we formally evaluated retailers’ perceptions of SSB taxes using semi-structured interviews (including open- and closed-ended questions) with 103 randomly selected retailers (50 corner and liquor stores; 28 chain convenience, drug, and mass-merchandise stores; 18 chain supermarkets and discount supermarkets; and 7 independent supermarkets) across 3 cities with SSB taxes (Berkeley, Oakland, and San Francisco); interviews occurred in 2018 and 2019 (approximately 3 years, 1 year and 6 months post tax-implementation, respectively). A majority of both small and large retailers reported the tax had only a minimal effect on their business (70%). About half of retailers believed that other cities should adopt SSB taxes (53%), and were supportive of a statewide SSB tax (53%), noting it would level the playing field and better support health in their communities. Retailers’ responses did not differ based on neighborhood income, and only 2 responses differed significantly between large and small retailers. Only 2 of 103 retailers reported raising the price of a non-beverage product in response to the tax, specifically raising the price of snack foods of low nutritional quality and alcoholic beverages. A majority of retailers in 3 California cities with SSB taxes have no concerns regarding the tax, endorse the health goals of SSB taxes and support statewide expansion of SSB tax policies.

Antiplatelet drugs: a review of pharmacology and the perioperative management of patients in oral and maxillofacial surgery

INTRODUCTION

An increasing number of patients are taking oral antiplatelet agents. As a result, there is an important patient safety concern in relation to the potential risk of bleeding complications following major oral and maxillofacial surgery. Surgeons are increasingly likely to be faced with a dilemma of either continuing antiplatelet therapy and risking serious haemorrhage or withholding therapy and risking fatal thromboembolic complications. While there are national recommendations for patients taking oral antiplatelet drugs undergoing invasive minor oral surgery, there are still no evidence-based guidelines for the management of these patients undergoing major oral and maxillofacial surgery.

METHODS

MEDLINE and EMBASE databases were searched to retrieve all relevant articles published to 31 December 2017.

FINDINGS

A brief outline of the commonly used antiplatelet agents including their pharmacology and therapeutic indications is discussed, together with the haemorrhagic and thromboembolic risks of continuing or altering the antiplatelet regimen in the perioperative period. Finally, a protocol for the management of oral and maxillofacial patients on antiplatelet agents is presented.

CONCLUSIONS

Most current evidence to guide decision making is based upon non-randomised observational studies, which attempts to provide the safest possible management of patients on antiplatelet therapy. Large randomised clinical trials are lacking.

Polio Elimination In Pakistan: Still A Dream?

Pakistan has failed to achieve polio elimination till yet. Poliomyelitis is a crippling childhood disease, which causes paralysis for life. Aim of this study is to compare the frequency of polio cases in different provinces of Pakistan from 2010 till 2017. Results showed that total of 144 cases of polio were reported in 2010, a rise up to 198 was reported in 2011, a decline in cases was seen in 2012, i.e., 58, again cases rouse up to 93 cases, in 2013. In 2014, 306 cases were reported the rate declined considerably in 2015, i.e., 54 cases and in 2016 only 20 cases were seen. In 2017 only 8 cases were reported. So, it can be concluded that progressive improvement is seen in Pakistan regarding polio. Focused efforts should be continued till its complete elimination from the country as this will also give a positive message to the world about Pakistan being a responsible and peaceful nation.

Ionic Liquid Based Nanocarriers for Topical and Transdermal Drug Delivery

In the pharmaceutical industry, there are challenges in topical and transdermal administration of drugs, which are sparingly soluble in water and most organic solvents. Ionic liquids (ILs) have been found to be very effective for dissolution of sparingly soluble drugs. However, hydrophilic IL-borne drugs cannot penetrate into or across the skin because of the highly hydrophobic barrier function of the outer skin. In this chapter we report a novel IL-in-oil (IL/o) microemulsion (ME) that is able to dissolve a significant amount of sparingly soluble drug, acyclovir, in the IL core while the continuous oil phase can provide the desired features for topical/transdermal transport through the skin. The ME is composed of a blend of the nonionic surfactants polyoxyethylene sorbitan monooleate (Tween 80) and sorbitan laurate (Span 20), isopropyl myristate (IPM) as an oil phase, and the IL [C1mim][(MeO)2PO2] (dimethylimidazolium dimethylphosphate) as a dispersed phase. The size and size distribution of the aggregates in the MEs were characterized by dynamic light scattering, showing formation of the nanocarrier in the size range 8–34 nm. In vitro drug permeation studies into and across the skin showed that the IL/o ME increased drug administration compared with other formulations. The safety profile of the new carrier was evaluated using a cytotoxicity assay on the human epidermal model LabCyte. We believe that these IL-assisted nonaqueous MEs can serve as a versatile and efficient nanodelivery system for sparingly soluble drug molecules.

Differences in outcomes between the JoyBar control and standard wheelchair joystick control on two maneuverability tasks: a pilot study

PURPOSE

To determine if older adult, novice wheelchair users who drive a power wheelchair with a JoyBar control complete maneuverability tasks in less time and with less error than those who drive a power wheelchair with a standard joystick control.

MATERIALS AND METHODS

A parallel randomized controlled trial design conducted at a medical rehabilitation and research centre with ambulatory older adults aged 60 and above (n = 27). The intervention was the JoyBar alternative wheelchair control. The primary outcome measure was total time to complete each of the two maneuverability tasks. The secondary outcome measure was total number of errors during each of the maneuverability tasks.

RESULTS

An independent, two sampled t-test was conducted and revealed that the JoyBar group took a greater amount of time to complete both maneuverability tasks than the control group (p < .05). No significant differences (p < .05) were found in rates of error on either task between the JoyBar and joystick groups.

CONCLUSIONS

Maneuverability of a powered wheelchair by novice wheelchair users was not improved through the use of the JoyBar when compared to a standard wheelchair joystick, as measured by rates of error and time to complete maneuverability tasks. Implications for rehabilitation Clients who are new to powered wheelchair use may perform maneuverability tasks faster, with equivalent accuracy, using a standard joystick versus the JoyBar. Clients who use a JoyBar may require adjustments to the programming of their wheelchair to ensure optimal performance. Additional training may be required to achieve proficiency in maneuverability tasks with a JoyBar versus a standard joystick.

Maternal Health Care Expenditure among Women in Rural Areas of Pakistan

Background:  With Pakistan failing to achieve Millennium Development Goals we have now entered into a new era of Sustainable Development Goals. Decreasing child mortality, improving maternal health and increasing the proportion of births by trained birth attendants, are the areas with unmet goals. As 29.5% of population of Pakistan is below the poverty line, expenditure on maternal health care services is of great importance as it determines the utilization of health care services to a large extent.Objective:  To assess maternal health care expenditure and its sociodemographic predictors in rural Khanewal, Punjab, Pakistan.Methodology:  In this cross sectional study average cost on delivery (both SVD and Cesarean section) was assessed in both public and private sector of ruralKhanewal. Total 257 women who had delivered in the last one year were included.Results:  Results revealed that 69.3% of mothers were illiterate.56.8% sought antenatal care in public health unit and 43.2% in a private health care facility. 49.8% delivered in a public health unit and 50.2% in private health care facility. Total expense on antenatal care and delivery was found to be <4,000PKR (<$38.16) in 55.6% (reportedly in a public health care unit) and was >16,000PKR (>$152.65) in 23.3% (reportedly in a private health care facility). A significant difference was found between expense, in public vs private sector and SVD vs. C-section.Conclusion:  This study revealed that there is high financial cost on maternal health services in both public and private sector of rural Khanewal. Although in private sector the cost is more as compared to public sector but still it is high keeping the notion of free health care services in Pakistan by the government. There-fore it is suggested to improve the quality of health care in public sector and if possible to provide free of cost services to mothers during delivery.

Teeth under High Occlusal Force may Reflect Occlusal Trauma-associated Periodontal Conditions in Subjects with Untreated Chronic Periodontitis

OBJECTIVE

To determine the association of high occlusal force (HOF) with the signs of occlusal trauma and periodontal conditions in periodontitis patients, and elaborate the relevant clinical implications.

METHODS

Periodontal parameters and signs of occlusal trauma were recorded for 807 teeth in 30 subjects with untreated chronic periodontitis. The T-scan II occlusal analysis system determined the HOF during maximum intercuspation, lateral excursion and protrusive excursion. The correlation of HOF with periodontal parameters and signs of occlusal trauma was analysed.

RESULTS

Overall, the teeth with HOF existed mainly in molars and presented with deeper probing depth (PD) and higher frequency of bleeding on probing (BOP) than those without HOF. The fixed-effect analysis showed that HOF was positively correlated with PD and BOP (P < 0.05) in posterior teeth; widened periodontal ligament space on radiographs in upper (r = 0.179, P < 0.01) and lower posterior teeth (r = 0.205; P < 0.05); as well as functional mobility in upper posterior teeth (r = 0.168; P < 0.05).

CONCLUSION

This study suggests that the posterior teeth with HOF in subjects with chronic periodontitis may reflect occlusal trauma-associated periodontal conditions that could probably increase the risk of further periodontal destruction. These findings may improve the clinical assessment of occlusal trauma and related periodontal conditions for better patient management and treatment outcomes.

Diameter-controlled synthesis of α-Mn2O3 nanorods and nanowires with enhanced surface morphology and optical properties

Single crystalline α-Mn(2)O(3) nanorods, and nanowires with and without nanoparticles on them have been successfully synthesized by a template-free hydrothermal route. The variation in hydrothermal temperature has not only affected the diameter of the nanostructure but also noticeably affected the morphology and optical properties of the α-Mn(2)O(3) nanostructure. The influence of temperature on the diameter, crystallinity, surface morphology and optical properties of the α-Mn(2)O(3) nanostructure have been characterized by x-ray diffraction, scanning electron microscopy, energy dispersive x-ray analysis, transmission electron microscopy, high resolution transmission electron microscopy, Raman spectroscopy and UV-visible spectroscopy and photoluminescent (PL) spectroscopy. The results showed in our experimental conditions that single crystalline nanorods of the α-Mn(2)O(3) were obtained at a temperature of 180 °C, while single crystalline nanowires were obtained by increasing the temperature to 240 and 300 °C. Nanowires with nanoparticles on them were obtained by increasing the temperature to 240 °C and nanowires without nanoparticles on them were obtained by increasing the temperature to 300 °C. The nanorods and nanowires obtained had a well-defined morphology. The nanowires synthesized at 300 °C exhibited an intense orange band PL spectrum.

Relationship of Age at First Live Birth, Parity and Duration of Breast Feeding with Non Familial Breast Cancer in Pakistani Women. A Study of the Cancer Research Group Pakistan

Background and objectives; This multicenter case control study is being conducted at seven different centers in Pakistan in order to find out the association and relationship of different hormonal and reproductive factors with breast cancer. These factors have been identified either as risk factors or protective factors for breast cancer in other communities but not in Pakistani women. Preliminary results from four centers are being reported here.Method; Patients attending these cancer treatment centers were interviewed by the trained medical personals and the findings were recorded in a proforma. Age and area matched unrelated controls were randomly selected and interviewed with same questions and findings were recorded in a corresponding proforma. SPSS version 11.5 was used for statistical analysis.Results; From June, 2008 to May, 2009 six hundred eighty eight cases were compared with an equal number of controls. Median age of cases was 47 years (26-70 years) and controls 47.5 years (25-71 years). One hundred ninety eight of cases (28.78%) and 208 of controls (30.23 %) gave first full term live birth before the age of 20. Sixty two cases (09.01%) and 38 controls (5.52%) gave first full term live birth after the age of 30. Seventy one cases and 65 controls were nulliparous.Fifty cases (07.27%) and 51 controls (07.41%) had only one child whereas 104 (15.12%) cases and 118 controls (17.15%) had more then 7 children.Breast feeding duration was more then 24 months in 410 (72.31%) of all women who had more then 1 child. Duration of breast feeding in cases Vs. control in women with 2-4 children, 5-7 children and more then 7 children was similar. Statistical analysis reveals that first live birth below the age of 20 and duration of breast feeding of greater then 24 months duration are not associated as protective factors in this patient population. Odds ratio of 1.35, 95% CI; 1.01-1.70 and 1.014, 95% CI; 0.80-1.22 respectively. Age at first live birth after 30 years of age seems to be positively associated with breast cancer. Odds ratio of 1.75, 95% CI; 1.15-2.65. These results do not support the young age at first full term pregnancy and prolonged duration of breast feeding as protective factors against the breast cancer.Key Words: Breast Cancer, Breast feeding, Parity, Risk Factor

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2071.

What is positive appendicitis? A new answer to an old question. Clinical, macroscopical and microscopical findings in 200 consecutive appendectomies

INTRODUCTION

The correlation between clinical and histopathology findings in appendicitis has been highlighted by many studies. However, the impact of this correlation on the surgical decision to remove a normal-looking appendix is still vague, with no clear definition of positive appendicitis. The aim of this study was to correlate the histological, operative and clinical diagnoses of acute appendicitis (AA).

METHODS

200 patients with a preoperative diagnosis of AA underwent laparoscopic appendectomy. A single consultant surgeon performed all the procedures. The clinical, macroscopical and microscopical outcomes were reported and analysed. Follow-up assessment was performed as an outpatient appointment.

RESULTS

112 women and 88 men were included in this study. The mean age was 18.8 (range 8-83) years. Macroscopical appendicitis was confirmed in 139 (69.5 percent) patients, while microscopical appendicitis was reported in 147 (73.5 percent) specimens of the appendix. Ten (7.2 percent) out of 139 patients who were macroscopically positive were found to have a normal appendix on microscopical examination. Different pathologies were found in 21 (10.5 percent) patients, and all underwent appendectomy. Microscopical appendicitis was confirmed in 10 (25 percent) out of 40 patients who had a normal-looking appendix.

CONCLUSION

The correlation of the clinical, microscopical and macroscopical findings in AA is important in order to understand the natural history of appendicitis, and this may help to formulate a sound surgical decision. These findings are supportive of justifying appendectomy for normal-looking appendices, if no other pathology is found.

Pneumomediastinum, stomach wall and hepatic portal vein gas secondary to partial necrosis of the stomach wall

The combination of pneumomediastinum, gastric wall gas and hepatic portal vein gas is a challenging clinical problem. Although different causes of the individual gas sign have been reported in the literature, the cause of a triad of these signs in a single patient is less clear, and represents an extremely rare condition. A 65-year-old man presented with severe lower chest and epigastric pain of a few hours' duration. Initial assessment confirmed epigastric tenderness. Computed tomography showed pneumomediastinum, air in the stomach wall, hepatic portal vein gas and bowel dilatation. Small bowel and right colon dilatation was confirmed at laparotomy. The patient was treated subsequently with antibiotics to cover Gram-positive and Gram-negative bacteria, and anaerobes. The patient was discharged in good general condition on the 12th postoperative day. In conclusion, the triad of pneumomediastinum, gastric wall gas and hepatic portal vein gas is an extremely rare condition and associated with gastric necrosis.

Continuous figure-of-eight suturing in upper and lower gastrointestinal anastomosis

INTRODUCTION

The optimal technique for gastrointestinal anastomosis is controversial. The three most popular techniques are two layers, one layer and the stapling method. However, there is no universal agreement on the best technique. The aim of this study was to evaluate the safety, feasibility, and efficacy of continuous figure-of-eight suturing in gastrointestinal anastomosis.

METHODS

This was a retrospective study of 170 patients who underwent gastrointestinal anastomosis using continuous figure-of-eight suturing for the first layer and continuous seromuscular suturing for the second layer from August 1993 to January 2006. All operations were performed by a single consultant surgeon. We assessed each anastomosis by checking the integrity, vascularity and patency, and also ensuring tension-free status. Postoperatively, patients were managed by routine care of intravenous fluids and nasogastric tube until they had active bowel sounds and started absorbing. Imaging was arranged for patients who developed clinical signs and symptoms of leak.

RESULTS

170 patients underwent gastrointestinal anastomosis by continuous figure-of-eight suturing for different pathologies over a two-and-a-half-year period. There were 92 (54.1 percent) men and 78 (45.9 percent) women. The mean age of the patients was 56 (range 20-88) years. The median follow-up was 74 months. There were 124 (72.9 percent) small bowel anastomosis and 46 (27.1 percent) large bowel anastomosis. An important complication after gastrointestinal anastomosis was leakage, which was reported in three (1.8 percent) patients. One of them had gastric cancer, one had Crohn's disease and one had intestinal ischaemia. No mortality was reported in relation to anastomotic failure. Two (1.2 percent) patients developed stenosis and 15 (8.8 percent) patients died because of progression of their disease or other pathologies during the follow-up.

CONCLUSION

Continuous figure-of-eight suturing is a simple, easy to learn, safe and satisfactory upper and lower gastrointestinal anastomosis technique.

Prevention of trocar site incisional hernia following laparoscopic ventral hernia repair

BACKGROUND AND OBJECTIVES

Trocar-site incisional hernia following laparoscopic ventral hernia repair is reported to have a relatively high incidence. The main reasons are trocar diameter and design, pre-existing fascial defects, and some operation- and patient-related factors. The aim of this article to show a new technique of ventral hernia repair that could prevent trocar site incisional hernia.

METHODS

After establishing the pneumoperitoneum, three 5-mm ports are inserted in positions according to the site and size of the hernia. The procedure begins by dissection of the adhesions of bowel loops or omentum (if any) from the hernia to clear a good margin for mesh coverage. Then a single 10-mm to 15-mm port (mesh insertion port) is inserted in the center of the ventral hernia depending on the size of the mesh. The mesh is fixed in position with a 5-mm tacker. The peritoneum and underlying superficial fascia are carefully closed before closing the skin.

RESULTS

A total of 35 patients were recruited for this method. The mean hospital stay was 1.5 days, the mean age was 50.35 years and the mean operative time was 40 minutes. In all patients, 10x15-cm ePTFE was used. No single incidence of trocar-site incisional hernia occurred during a mean follow-up of 2 years. Three (8.57%) patients developed complications and no mortality was reported.

CONCLUSION

The mesh introduction through the port, which is situated at the center of the hernia defect is a simple, cost-effective technique and will prevent trocar-site incisional hernia.

A survey of the preparedness for an influenza pandemic of general practitioners in the West Midlands, UK

There is a lack of evidence regarding the preparedness of general practitioners (GPs) to respond to pandemic influenza. A postal questionnaire survey was conducted to explore the self-perceived pandemic preparedness of GPs in the West Midlands, United Kingdom, and to determine differences between urban and non-urban GPs. The postal questionnaire was sent out to 773 GPs in November 2005, and a reminder was sent in January 2006. In all, 427/773 (55%) questionnaires were returned, and 56% of respondents were aware of influenza pandemic preparedness plans. Approximately one-quarter of respondents (28%, 114/401) thought the response of their practice to a pandemic event would be very poor/poor. Non-urban GPs were significantly more likely to rate the response of their practice to a pandemic as likely to be poor (OR 3.01, 95%CI 1.03–8.76) and were less likely to be aware of pandemic preparedness plans (OR 0.62, 95%CI 0.39–0.99). Non-urban GPs were also significantly more likely to feel less confident in their ability to explain to their patients what to do and why during an influenza pandemic than GPs based in urban areas (OR 4.68, 95%CI 1.78–12.31). GPs rating of the odds of a pandemic affecting the United Kingdom did not differ significantly by geographic location. The results of this paper can be used to inform and influence public health policy and as evidence of a need to provide additional education and training to improve pandemic preparedness among GPs, in particular those in non-urban areas.

Viral hemorrhagic fever in Pakistan: awareness among health care personnel

OBJECTIVE

To assess the level of knowledge regarding viral hemorrhagic fever (VHF) among healthcare personnel at two largest tertiary care hospitals in Karachi, Pakistan.

METHODS

A cross sectional convenience survey was conducted in February 2001 among doctors, nurses, laboratory technicians and janitors/orderlies of Jinnah Postgraduate Medical Centre and Civil Hospital, Karachi. The questionnaire included demographic information with their designation and knowledge level regarding VHF management, spread and prevention. Frequencies of the answers to each question were calculated for all questions and scores were assigned. The frequencies were also calculated on the basis of the designation of the respondent so that each group could be examined separately.

RESULTS

A total of 187 healthcare personnel (121 doctors, 31 nurses, 19 laboratory technicians and 16 janitors/orderlies) were interviewed. Forty three percent (81) respondents were males and 57% (106) were females. By designation 90% doctors, 71% nurses, 32% laboratory technicians and 6% janitors knew about VHF. Only 57% doctors (69) knew the common signs and symptoms of VHF. Isolation for affected patients was suggested by 65% nurses and 6% janitors. Knowledge regarding burial procedure of dead patients was low in all groups.

CONCLUSION

Differences in knowledge of different groups is obvious but it is essential to raise the knowledge regarding VHF at all levels including the housekeeping staff. There is also a need for continuing medical education (CME) for all health care personnel for the emerging health problems in Pakistan.

The optical stretcher: a novel laser tool to micromanipulate cells

When a dielectric object is placed between two opposed, nonfocused laser beams, the total force acting on the object is zero but the surface forces are additive, thus leading to a stretching of the object along the axis of the beams. Using this principle, we have constructed a device, called an optical stretcher, that can be used to measure the viscoelastic properties of dielectric materials, including biologic materials such as cells, with the sensitivity necessary to distinguish even between different individual cytoskeletal phenotypes. We have successfully used the optical stretcher to deform human erythrocytes and mouse fibroblasts. In the optical stretcher, no focusing is required, thus radiation damage is minimized and the surface forces are not limited by the light power. The magnitude of the deforming forces in the optical stretcher thus bridges the gap between optical tweezers and atomic force microscopy for the study of biologic materials.

Inhibitory effect of curcumin, a food spice from turmeric, on platelet-activating factor- and arachidonic acid-mediated platelet aggregation through inhibition of thromboxane formation and Ca2+ signaling

Curcumin, a dietary spice from turmeric, is known to be anti-inflammatory, anticarcinogenic, and antithrombotic. Here, we studied the mechanism of the antiplatelet action of curcumin. We show that curcumin inhibited platelet aggregation mediated by the platelet agonists epinephrine (200 microM), ADP (4 microM), platelet-activating factor (PAF; 800 nM), collagen (20 microg/mL), and arachidonic acid (AA: 0.75 mM). Curcumin preferentially inhibited PAF- and AA-induced aggregation (IC50; 25-20 microM), whereas much higher concentrations of curcumin were required to inhibit aggregation induced by other platelet agonists. Pretreatment of platelets with curcumin resulted in inhibition of platelet aggregation induced by calcium ionophore A-23187 (IC50; 100 microM), but curcumin up to 250 microM had no inhibitory effect on aggregation induced by the protein kinase C (PKC) activator phorbol myrsitate acetate (1 microM). Curcumin (100 microM) inhibited the A-23187-induced mobilization of intracellular Ca2+ as determined by using fura-2 acetoxymethyl ester. Curcumin also inhibited the formation of thromboxane A2 (TXA2) by platelets (IC50; 70 microM). These results suggest that the curcumin-mediated preferential inhibition of PAF- and AA-induced platelet aggregation involves inhibitory effects on TXA2 synthesis and Ca2+ signaling, but without the involvement of PKC.