Respected but stigmatized: Healthcare workers caring for COVID-19 patients

BACKGROUND

Healthcare workers (HCWs) caring for Corona Virus Disease 2019 (COVID-19) patients are at increased risk of being stigmatized, which compromises their individual mental well-being and the quality of care they deliver. Stigma-reduction interventions may (partly) prevent this. However, there is a lack of in-depth understanding of the experiences and underlying causes of COVID-19 stigma among HCWs, which is needed to design such interventions. We conducted in-depth semi-structured interviews to assess COVID-19 stigma among COVID-19 HCWs in Ireland, Nigeria, The Netherlands, Pakistan, and The Philippines.

METHODS

We used a purposive and snowball sampling to recruit a total of 53 HCWs for online interviews (13 in Ireland; 15 in Nigeria; 6 in The Netherlands; 6 in Pakistan; and 13 in The Philippines (2021). After verbatim transcribing interviews, we used a thematic approach for data analysis.

RESULTS

In all countries, stigmatization of COVID-19 HCWs is driven by fear of infection and the perception of HCWs being carriers of the disease amplified by them wearing of scrubs and personal protective equipment. There were differences between countries in the way stigma manifested in self- anticipated and experienced stigma like scolding, discrimination, avoidance, (self-) isolation, and exclusion in public, in the community, at work, and in the household. The stigma resulted in feelings of depression, loneliness, isolation, and the desire to quit one's job.

DISCUSSION

COVID-19 HCWs from all countries experienced all forms of stigmatization related to their work as a COVID-19 frontliner. This affected their mental well-being, which in turn affects job performance and quality of care, there is a high need to develop stigma reduction tools for HCWs.

Fragment-based in silico design of SARS-CoV-2 main protease inhibitors

3CLpro is essential for SARS-CoV-2 replication and infection; its inhibition using small molecules is a potential therapeutic strategy. In this study, a comprehensive crystallography-guided fragment-based drug discovery approach was employed to design new inhibitors for SARS-CoV-2 3CLpro. All small molecules co-crystallized with SARS-CoV-2 3CLpro with structures deposited in the Protein Data Bank were used as inputs. Fragments sitting in the binding pocket (87) were grouped into eight geographical types. They were interactively coupled using various synthetically reasonable linkers to generate larger molecules with divalent binding modes taking advantage of two different fragments' interactions. In total, 1,251 compounds were proposed, and 7,158 stereoisomers were screened using Glide (standard precision and extra precision), AutoDock Vina, and Prime MMGBSA. The top 22 hits having conformations approaching the linear combination of their constituent fragments were selected for MD simulation on Desmond. MD simulation suggested 15 of these did adopt conformations very close to their constituent pieces with far higher binding affinity than either constituent domain alone. These structures could provide a starting point for the further design of SARS-CoV-2 3CLpro inhibitors with improved binding, and structures are provided.

Novel dark-blood versus conventional bright-blood late gadolinium enhancement CMR: A pilot study comparing impact on myocardial ischaemic burden

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation

Background

In patients with coronary artery disease (CAD), increasing myocardial ischaemic burden (MIB) is a strong predictor of adverse events. When measured by cardiovascular magnetic resonance (CMR), a MIB ≥12.5% is considered significant and often used as a threshold to guide revascularisation. Ischaemic scar can cause stress perfusion defects which do not represent ischaemia and should be excluded from the MIB calculation. Conventional bright-blood late gadolinium enhancement (LGE) is able to identify ischaemic scar but can suffer from poor scar-to-blood contrast, making accurate assessment of scar volume difficult. Dark-blood LGE methods increase scar-to-blood contrast and improve scar conspicuity which may impact the calculated scar burden and consequently the estimation of MIB when read in conjunction with perfusion images.

Purpose

To evaluate the impact of dark-blood LGE versus conventional bright-blood LGE on the estimation of MIB in patients with CAD.

Methods

37 patients with suspected or known CAD who had evidence of CMR stress perfusion defects and ischaemic scar on LGE imaging were recruited. Patients underwent adenosine stress perfusion imaging followed by dark-blood LGE then conventional bright-blood LGE imaging at 3T. For dark-blood LGE, phase sensitive inversion recovery imaging with a shorter inversion time to null the LV blood-pool was used without any additional magnetization preparation. For each patient, three short-axis LGE slices were selected to match the three perfusion slice locations. Images were anonymised and analysed in random order. Ischaemic scar burden (ISB) was quantified for both LGE methods using a threshold >5 standard deviations above remote myocardium. Perfusion defect burden (PDB) was quantified by manual contouring of perfusion defects. MIB was calculated by subtracting the ISB from the PDB.

Results

MIB calculated using dark-blood LGE was 19% less compared to bright-blood LGE (15.7 ± 15.2% vs 19.4 ± 15.2%, p < 0.001). There was a strong positive correlation between the two LGE methods (rs = 0.960, p < 0.001, Figure 1A). Bland-Altman analysis revealed a significant fixed bias (mean bias = -3.6%, bias 95% CI: -2.6 to -4.7%, 95% limits of agreement: -9.8 to 2.5%) with no proportional bias (Figure 1B). MIB was calculated ≥12.5% and <12.5% by both LGE methods in 19 (51%) and 12 (32%) patients respectively. In 6 patients (16%), MIB was ≥12.5% using bright-blood LGE and <12.5% using dark-blood LGE (Figure 1A – orange data points). Overall, when used to classify MIB as <12.5% or ≥12.5%, there was only substantial agreement between the two LGE methods (κ=0.67, 95% CI: 0.45 to 0.90).

Conclusions

The use of dark-blood LGE in conjunction with perfusion imaging results in a lower estimate of MIB compared to conventional bright-blood LGE. This can cause disagreement around the threshold of clinically significant ischaemia which could impact clinical management in patients being considered for coronary revascularisation.

Abstract Figure. Linear regression with corresponding B&A

Study of the histidine complex of uranium(IV): synthesis, spectrophotometric, magnetic and electrochemical properties

We synthesized the novel histidine complex of uranium(IV). A 1:3 mole ratio was found between metal and ligand by the mole ratio method, while –NH2 and –COO– groups of histidine behave as coordinating sites. The IR spectra confirmed the lone pair donating or coordinating sites. The elemental analysis confirmed the stoichiometry. The bathochromic shift with an increase in the optical density in the UV-Visible range indicated that the compound and its central metal ion hold uniform electronic charge distribution. The electrochemical results indicated a quasi-reversible (neither completely reversible nor completely irreversible) oxidation of the complex to its uranium(V) product at the platinum working electrode. The quasi-reversible process shows a comparatively slow electron transfer (ET) rate with the heterogeneous electron transfer rate constant ‘ks’ (3.4 ×  10–4 cm s-1) at 50 mV s-1 and 305 ± 0.5 K. The kinetics such as diffusion and charge transfer lead the reaction with an ECE (electrochemical–chemical–electrochemical) mechanism. The thermodynamic parameters of activation such as ΔH*; 4.257 kJ mol–1, ΔS*; -2.519 × 10–3 J mol–1 K–1 and ΔG* 4.26 kJ mol–1 helped to propose an associative mechanism of the electron transfer at the platinum working electrode.                     KEY WORDS: Uranium, Histidine, Spectroscopy, Electrochemistry, Kinetics   Bull. Chem. Soc. Ethiop. 2020, 34(3), 557-569.  DOI: https://dx.doi.org/10.4314/bcse.v34i3.11

Extensive Crystallographic Fragment-Based Approach to Design SARS CoV2 3CLpro Main Protease Inhibitors and Related Metadata.. [DOI: 10.26434/chemrxiv.13550246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

<p>3CLpro is a vital protein for the SARS-CoV-2 replications and its inhibition using small molecules is a <i>bona fide</i> approach used to develop new drugs against the virus. In this study, a comprehensive crystallography-guided fragment-based drug discovery approach was employed to design new inhibitors for SARS-CoV-2 3CLpro. Protein Data Bank was explored to find small molecules cocrystallized with SARS-CoV-2 3CLpro. The fragments sitting in the binding pocket (87) were interactively coupled using various linkers with the intention to get molecules having the same orientation as those of the constituting fragments. In total, 1251 couples were prepared and converted to maximum possible stereoisomers using LigPrep for screening using Glide (standard precision and extra precision), AutoDock Vina, and Prime MMGBSA. Top 22 hits having conformations similar to their cocrystallized fragments were selected for MD simulation on Desmond. MD simulation suggested that 15 hits had conformations very close to their constituting fragments. Results indicated that these hits were computationally reliable and could be considered for further development. This suggests that the study could provide a benchmark starting point for the further design of SARS-CoV-2 3CLpro inhibitors with improved binding (data provided). <br></p>

Extensive Crystallographic Fragment-Based Approach to Design SARS CoV2 3CLpro Main Protease Inhibitors and Related Metadata.. [DOI: 10.26434/chemrxiv.13550246.v1]

3CLpro is a vital protein for the SARS-CoV-2 replications and its inhibition using small molecules is a bona fide approach used to develop new drugs against the virus. In this study, a comprehensive crystallography-guided fragment-based drug discovery approach was employed to design new inhibitors for SARS-CoV-2 3CLpro. Protein Data Bank was explored to find small molecules cocrystallized with SARS-CoV-2 3CLpro. The fragments sitting in the binding pocket (87) were interactively coupled using various linkers with the intention to get molecules having the same orientation as those of the constituting fragments. In total, 1251 couples were prepared and converted to maximum possible stereoisomers using LigPrep for screening using Glide (standard precision and extra precision), AutoDock Vina, and Prime MMGBSA. Top 22 hits having conformations similar to their cocrystallized fragments were selected for MD simulation on Desmond. MD simulation suggested that 15 hits had conformations very close to their constituting fragments. Results indicated that these hits were computationally reliable and could be considered for further development. This suggests that the study could provide a benchmark starting point for the further design of SARS-CoV-2 3CLpro inhibitors with improved binding (data provided).

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Correlation of bile acids and aspartate-aminotransferase with outcomes in cholestasis of pregnancy

OBJECTIVE

To identify laboratory data that correlates with poor perinatal outcomes.

METHODS

A retrospective chart review of women with intrahepatic cholestasis of pregnancy (ICP), admitted for delivery between January 1, 2013 and December 31, 2017, was performed. Chi-square, student's t-test, and ANOVA statistical analysis was performed. The receiver-operator characteristic curves were plotted for the prediction of each category of perinatal outcome and the areas under the curves were determined. All p-values were two-sided, and p < 0.05 was considered statistically significant.

RESULTS

Analysis of the 61 ICP cases showed no occurrence of the intrauterine fetal demise (IUFD), stillbirth, abruption, or neonatal demise. ROC curve analysis revealed a statistically significant correlation between bile acid and AST levels and perinatal outcomes. A bile acid (BA) level equal to or greater than 37μmol/L strongly predicted spontaneous preterm labor in women affected by ICP with a sensitivity of 100% and specificity of 60.70% (p = 0.002). A BA level equal to or greater than 42μmol/L strongly predicted meconium-stained amniotic fluid with a sensitivity of 85.70% and specificity of 66.70% (p = 0.006). AST levels equal to or greater than 62 IU/L strongly predicted NICU admission with a sensitivity of 81.30% and specificity of 62.20% (p = 0.002). AST levels equal to or greater than 75 IU/L strongly predicted hyperbilirubinemia in the neonates with a sensitivity of 87.50% and specificity of 69.80% (p = 0.001).

CONCLUSIONS

There is a statistically significant correlation between elevated BA and elevated AST levels and adverse perinatal outcomes.

Description of Renal Biopsy in Frequently Relapsing and Corticosteroid Non Responsive Nephrotic Syndrome in Childhood

A study of 71 children with nephrotic syndrome admitted to the Department of Child Health, Medical School, Sriwijaya University Palembang General Hospital between November 1981 and November 1983 has been reported. Of the 71 children, there were 50 (70.4%) boys and 21 (29.6%) girls, in which 31 were less than 6 years of age. During the first eight weeks complete rem1sswn was found in 66 patients. The other five were steroid resistant. Among the 66 patients who responded to steroid, 61 had remission with the first 4 weeks. Further observation up to two years, 3 patients were still in remission, 36 had one relapse and 22 had frequent relapses. The other 5 patients, who had remission on the second 4 weeks, one had one relapse, two had frequent relapses and the other two were not available for follow up. Renal biopsy was performed in 31 patients. The representative results of the renal biopsy were found in only 20 patients : Eleven patients showed minimal change nephrotic syndrome (MCNS). Ten of these patients had frequent relapses while one patient was steroid resistant. Two had renal insufficiency. Three patients had focal glomerulosclerosis (FGS); two of them were frequently relapsing patients and the other one had steroid resistant. Four patients had mesangial proliferative glomerulonephritis (Mes. PGN). All of them had frequent relapses. One patient with diffuse proliferative glomerulonephritis (DPGN) was steroid resistant. One patient with crescentic glomerulonephritis (CrGN) was also steroid resistant.

Cerebrospinal fluid procalcitonin as a biomarker of bacterial meningitis in neonates

OBJECTIVE

The objective of the study was to study the performance of cerebrospinal fluid (CSF) procalcitonin as a marker for bacterial meningitis in neonates, and to determine its optimal 'cutoff' in CSF that can be called significant for the diagnosis.

STUDY DESIGN

Neonates qualifying for lumbar puncture were prospectively studied. Procalcitonin and established CSF parameters were recorded.

RESULTS

At a cut-off value of 0.33 ng ml^-1, CSF procalcitonin had a sensitivity of 0.92, specificity of 0.87, with positive and negative likelihood ratios of 7.13 and 0.092, respectively. The area under the curve for different CSF parameters was: 0.926 (0.887 to 0.964) (P<0.001) for procalcitonin, 0.965 (0.956 to 0.974) for total leukocyte count, 0.961 (0.94 to 0.983) for neutrophil count, 0.874 (0.825 to 0.923) for protein, 0.946 (0.914 to 0.978) for sugar and 0.92 (0.955 to 0.992) for CSF:serum sugar ratio. The lumbar puncture was traumatic in 36 (21.4%) patients; out of these 15 (41.7%) had bacterial meningitis and 21 (58.3%) had no meningitis. In traumatic lumbar tap group, the median (IQR) CSF procalcitonin in patients with and without meningitis was 1.41 (0.32-3.42) ng/ml and 0.21(0.20-0.31) ng/ml respectively (p<0.05).

CONCLUSIONS

Procalcitonin measurement has diagnostic efficiency similar to the established CSF markers. Routine assessment of procalcitonin in clean non-contaminated CSF may not yield additional information, but it may have clinical utility in situations where diagnosis of meningitis is in dilemma, as in the case of blood contamination of CSF in traumatic lumbar punctures.

Profil Kecukupan Asupan Makanan pada Rawat Inap

Latar belakang. Kekurangan Jumlah asupan makanan pasien rawat inap sering kali ditemukan.Tujuan. Mengetahui profil kecukupan asupan makanan pada pasien anak rawat inap. Metode. Penelitian cross sectionaldilakukan November 2011- Januari 2012 pada pasien anak rawat inap di RSUP Dr. Mohammad Hoesin, Palembang. Sampel dipilih secara consecutivedengan kriteria usia >1-10 tahun, dirawat >24 jam, tidak menderita sakit kritis, bukan gizi buruk, tidak terdapat kontraindikasi makan per oral, tidak terdapat masa atau asites diberikan asupan nutrisi berdasarkan buku rekomendasi IDAI tentang asuhan nutrisi pediatrik. Data asupan makan dihitung setelah perawatan 3 hari rawat dan data dianalisis dengan uji Fisher. Asupan dinyatakan tidak cukup apabila asupan rata-rata energi dan protein 3 hari pertama <80% kebutuhan.Hasil. Didapatkan 105 pasien yang diteliti, terbanyak usia 6-10 (59%) tahun, jenis kelamin perempuan (52%), status gizi baik (52%). Umur 1–5 tahun, asupan energi tidak cukup 27,9%; asupan protein tidak cukup 34,9%. Umur 6–10 tahun, asupan energi tidak cukup 50%; asupan protein tidak cukup 37,1%. Anak laki-laki, asupan energi tidak cukup 36%; asupan protein tidak cukup 15 30%. Anak perempuan, asupan energi tidak cukup 45,5%; asupan protein tidak cukup 41,8%. Gizi baik, asupan energi tidak cukup 38,2%; asupan protein tidak cukup 36,4%. Gizi kurang, asupan energi tidak cukup 44%; asupan protein tidak cukup 36%.Kesimpulan. Ketidakcukupan energi dan protein lebih banyak dialami oleh perempuan dan kelompok umur 6–10 tahun.

Pharmacological agents for reducing the haemodynamic response to tracheal intubation in paediatric patients: a systematic review

The primary aim of this review was to assess the effect of pharmacological agents administered to attenuate the haemodynamic response to tracheal intubation in paediatric patients up to 16 years of age undergoing elective surgery. Secondary aims were to identify adverse effects related to these agents, and the agents' roles in decreasing arrhythmias. A systematic search was conducted for articles listed in PubMed, CINAHL or the Cochrane database between January 1980 and June 2014. We included randomised controlled trials where the stated aim of the study included observing the effects of pharmacological agents on the haemodynamic response to tracheal intubation. The outcome measures were changes in mean, systolic and diastolic blood pressure and heart rate, adverse effects of drugs and arrhythmias. Sixteen publications with a total of 1408 children (ages two to 15 years) were identified. These studies varied in methodology and quality. Opioids were the commonest agents used and appeared to obtund the response in a dose-related manner. Fentanyl 2 µg/kg, remifentanil 1 µg/kg, sufentanil 0.1 and 0.2 µg/kg and alfentanil 25 µg/kg blunted the haemodynamic response. Remifentanil 3 µg/kg and sufentanil 0.3 µg/kg were the most effective in obliterating the response but led to hypotension in unstimulated patients. Opioid-related side-effects and arrhythmias were observed in few patients. We recommend that when required, the safe and effective doses identified in this review be used to obtund the haemodynamic response to intubation in paediatric patients, with close observation for the uncommon but recognised side-effects.

Micropropagation and Attempts to Develop RAPD Molecular Markers for Salt Tolerant Cultivars of Pearl Millet

Differences were observed among four salt tolerant cultivars of pearl millet to in vitro culture media. Among the four cultivars, Cv IP 6098 is the most salt sensitive had maximum number of multiple shoots (15)/ seed, and the more salt tolerant cvs IP 6106 and IP 22269 developed 3-6 shoots/seed while cv IP 19612 the seeds remained single shooted in MS+3.0mg/L media up to 7 months. The multiple shoots 20% of cv IP 6098, flowered in 5 months with the reduction in hormone concentration (MS+1.0 mg/L BAP) whereas, the other three cultivars did not flower under the tested conditions. The present study was carried to detect genetic differences among the four cultivars of pearl millet at molecular level through RAPD PCR markers. RAPD analysis was carried with 12 primers, each 10-mer, only 7 primers were amplified showed polymorphism for the four cultivars. Primer OPM 16 revealed a single unique band of approx. 485bp in the genotype IP 22269 and three polymorphic bands in the genotype IP 6106. The results were repeatable, and further studies in this direction may enable to link the single band in the genotype IP 22269 to a morphological trait or physiological condition like salt tolerance.

Lack of germ line changes in KISS1 and KAI1 genes in sporadic head and neck cancer patients of Pakistani origin

BACKGROUND

Head and neck cancer is included among the top five most commonly prevailing cancers worldwide. Abnormalities of either genetic or epigenetic factors are found responsible for the development and progression of head and neck cancer. Metastasis is the leading cause of death in patients with head and neck cancer. Down regulation of metastasis suppressor genes (MSGs) expression have been frequently observed in advanced tumours.

METHODOLOGY

The present study was designed to screen two of the most frequently down-regulated MSGs (KISS1 and KAI1) for mutations in 120 diagnosed head and neck cancer affected Pakistani patients. The questionnaire was filled for basic information about age, gender, smoking habits and area of cancer affected and other relevant details. Primers for both genes were designed using "Primer 3" software in such a way that both intron exon boundaries were included in this region. DNA isolation and estimation was done by using organic method and agarose gel electrophoresis. Single Strand conformational polymorphism technique was used after amplification of the respective genes. Mobility patterns were analyzed using BioDoc Analyzer.

RESULTS

Data of patients were analyzed on the basis of age, sex and type of cancer as variables. The mean age of patients and controls was 44 years. There were 53% females and 47% males in this group of study, 63% nonsmokers and 37% smokers and larynx cancer was found to be most frequent type of cancer with a percentage of 64. Lack of germ line mutation was observed in the entire coding region in both coding regions as well as splice sites of the respective genes.

CONCLUSION

Germ line mutations in KISS1 and KAI1 are thus considered to be a less frequent event in head and neck cancer patients. However, two polymorphisms in intronic region of exon 3 and exon 9 of KAI1 gene were observed in 1% of patients. In non coding region downstream of exon 3 (KAI1), there was a C 29166 T substitution and in intronic region upstream exon 9 of KAI1 gene, a C 52840 A substitution was observed. Both patients were females with ages 47 and 50 years respectively. A detailed analysis of regulatory mechanism is required to explore the genetic basis of down regulation of these MSGs for a better understanding of head and neck cancer progression.

Campomelic dysplasia: case report and review

Initial ultrasound of a fetus in the third trimester demonstrated shortened and bent fetal extremities with a narrow and misshapen thorax. These findings were suggestive of a fetus affected with a possible lethal skeletal dysplasia. Decisions regarding antepartum, intrapartum and neonatal care were made in this context. A newborn with campomelic dysplasia was delivered and suffered a rapid downhill course.

[Establishment of routines for elective laparoscopic surgery]

BACKGROUND

During the autumn of 1999, elective laparoscopic cholecystectomy was introduced as a new surgical procedure in the Central Hospital Østfold, Askim. A prospective evaluation of perioperative patient logistics and patient satisfaction was performed.

MATERIAL AND METHODS

214 patients were evaluated in the ambulatory; 116 of them were scheduled for operation. The operations were performed in general anaesthesia with continuous infusion of propofol and short acting opioides. Analgetics and anti-emetics were given pre- and perioperatively as prophylaxis against postoperative pain and nausea.

RESULTS

There were three unexpected cancellations. Two patients had serious postoperative bleedings and two had symptoms indicating residual bile duct stones. Twenty-eight patients (24%) were discharged on the same day. 114 patients (98%) were satisfied with their stay in hospital.

INTERPRETATION

The established patient logistics proved efficient and rational.

Infective endocarditis in children--incidence, pattern, diagnosis and management in a developing country

BACKGROUND

In developing countries, patients with infective endocarditis are referred late, there is low yield of blood cultures and incidence of rheumatic heart disease is still high.

OBJECTIVE

Evaluate clinical pattern, assess diagnostic criteria in our settings and determine outcome.

SETTING

A tertiary referral center for paediatric and adult cardiology.

PATIENTS AND METHODS

All children with infective endocarditis admitted to a single center from April 1997 to March 2000 were analysed. The diagnosis was based on Duke's criteria, which proposed two major and six minor criteria. Minor criteria were expanded to include raised acute phase reactants and presence of newly diagnosed or increasing splenomegally. The patients were stratified as definite, possible and rejected cases.

RESULTS

Of 1402 hospital admissions, 45 patients fulfilled the diagnostic criteria for infective endocarditis giving an incidence of 32 per 1000 hospital admissions. The mean age was 7.9 +/- 4 years (4 months to 16 years) with only two patients under 1 year of age. Rheumatic heart disease was the underlying lesion in 24 patients (53%) while congenital heart lesions occurred in 20 patients (45%). Previous antibiotic treatment was given in 26 patients (58%) definitely. Blood cultures were positive in 21 patients (47%); Streptococcus Viridans being the most common organism, while vegetations on echocardiography were present in 32 patients (71%). Surgery was undertaken in four patients and five patients left against medical advise. Of 10 patients with aortic valve involvement, there were three deaths (30%) and overall mortality was 13% (six patients).

CONCLUSIONS

The incidence of infective endocarditis is 32 per 1000 (3.2%) hospital admissions in a tertiary paediatric cardiology referral center. Rheumatic heart disease is still the most common underlying heart lesion. Blood cultures are positive in less than 50% of cases and echocardiography in expert hands is a more sensitive tool in our set up. Mortality is still high and aortic valve involvement in particular, carried poor prognosis.

[Functional outcome after reservoir surgery in ulcerative colitis]

BACKGROUND

The aim of this study was to examine whether the functional result of restorative proctocolectomy for ulcerative colitis deteriorated by postponing follow-up from three to eight years after pouch surgery.

MATERIAL AND METHODS

All patients (n = 58) operated for ulcerative colitis from 1984-97, who still had intact reservoir, responded to a questionnaire on defecating pattern, stool leakage, perianal irritation, urinary function, workload, sexual life, social life, and the patient's opinion on outcome. The results for the first 29 patients were compared to last 29 patients operated. Median follow-up was eight for the first 29 patients and three years for the last 29.

RESULTS

There were no significant difference in functional outcome and patient opinion after pouch surgery between the first 29 and last 29 patients (n = 58). Respective figures for median 24-hour stool frequency were 7.0 and 6.3, leakage of stool 48% and 38%, ability to defer defecation 86% and 97%, perianal irritation 59% and 48%, use of antidiarrhoeal medication 55% and 52%, and wearing of pad 28% and 38%. Sexual life (n = 57) had improved for 11 (19%) and deteriorated for seven patients (12%). Potency was reduced in five (15%) and ejaculation in four patients (12%), one of whom (3%) had retrograde ejaculation. Three (5%) had received a disability pension and five (9%) had reduced workload. After the pouch operation 48 (91%) felt better and three (6%) felt worse because of frequent bowel emptying (n = 3), perianal eczema (n = 1) and pouch fistula (n = 1).

INTERPRETATION

The results do not demonstrate any significant deterioration of functional outcome after pouch surgery for ulcerative colitis by postoperative increase of follow-up from three to eight years.

Morbidity and functional outcome after restorative proctocolectomy for ulcerative colitis

OBJECTIVE

To find out whether a threefold increase in follow up (median 108 compared with 36 months) influenced major morbidity and functional outcome between the first 32 and the last 32 patients consecutively operated on with J-pouch ileoanal anastomosis for ulcerative colitis from 1984 to 1997.

DESIGN

Retrospective and prospective study.

SETTING

University hospital, Norway.

PATIENTS

64 patients with ulcerative colitis who had proctocolectomy and ileal pouch-anal anastomoses.

INTERVENTIONS

The pouches were mainly hand anastomosed (n = 61) to the dentate line after mucosectomy or anastomosed by double stapling technique without mucosectomy (n = 3). The 58 patients who still had their pouches responded to a questionnaire on functional outcome and satisfaction.

MAIN OUTCOME MEASURES

Morbidity, functional outcome, and patients' satisfaction.

RESULTS

Major morbidity in these 64 patients comprised pelvic sepsis in 3 (5%), operation for intestinal obstruction in 5 (8%), pouchitis in 12 (19%), fistulas in 7 (11%) and pouch excision in 6 (9%). Thirteen patients (20%) had 35 reoperations and 11 patients (17%) had 22 re-laparotomies. There were more complications among the first 32 patients with the longest follow up than among the last 32 patients, but this difference was significant only concerning the rate of reoperations (31% compared with 9%) because of the higher number of pouch excisions (5 compared with 1) in this group. There were no significant differences in the functional outcome and degree of patient satisfaction between the first 29 and the last 29 patients. Respective values for 24 hour median stool freqency were 7.0 and 6.3, leakage of stool 48% and 38%, ability to defer defaecation 86% and 97%, perineal irritation 59% and 48%, use of antidiarrhoeal medication 55% and 52%, and wearing of pad 28% and 38%. Sexual life (n = 57) was improved in 11 (19%) and reduced in 7 (12%). Potency was reduced in 5 (15%) and ejaculation in 4 (12%), one of whom (3%) had retrograde ejaculation. Three (5%) received disability pensions and five (9%) had reduced workload. After the pouch operation 48 (91%) felt better and 3 (6%) felt worse because of frequent bowel emptying, perineal eczema, or pouch fistula.

CONCLUSION

Continence-preserving proctocolectomy carries considerable morbidity, but the long term functional outcome is satisfactory and does not seem to deteriorate substantially.

[Surgical treatment of ulcerative colitis]

Continence-preserving coloproctectomy for ulcerative colitis is technically demanding and is relatively often afflicted with complications. We have retrospectively reviewed the files of all patients being operated for ulcerative colitis at Ullevål Hospital from 1992 to 1997 (n = 53). Most of the patients (n = 50) were examined clinically; 12 patients had anal manometry before and after operation. 44 patients were operated with continence-preserving coloproctectomy with J-pouch and handsewn anastomosis; of these, 42 were followed more than six months. Eight had pouchitis, four perianal abscess/fistula, three septicaemia and three were operated for ileus. Two had anastomotic leakage and pelvic abscess that required transanal drainage. One had the pouch removed six years after operation due to chronic pouchitis and pouch-vaginal fistula. There was no deterioration of anal maximal resting and squeezing pressures on pre- and post-operative anal manometry. Mean number of stools from the reservoir per 24 hours were 6.2 (range 3-11); 11 patients had leakage of air and loose stool, three at day-time and eight at night. Two patients (4%) died from colorectal cancer and three (7%) had Crohn's disease. Nine patients were unfit for pouch surgery and underwent coloproctectomy (n = 7) or subtotal colectomy (n = 2). Our results indicate that pouch surgery for ulcerative colitis is a good option for most patients.

A survey of atrial fibrillation in general practice: the West Birmingham Atrial Fibrillation Project

BACKGROUND

The management of atrial fibrillation (AF) has changed substantially in recent years, especially with a greater appreciation of the prophylactic role of antithrombotic therapy against stroke. There is therefore a need for further information on the prevalence of AF in Britain, the prevalence of (and contraindications to) anticoagulant treatment, and the factors that influence doctors' decisions in treating AF, including the investigation of patients with this arrhythmia.

AIM

To investigate the prevalence, clinical features and management of patients with AF in a general practice setting.

METHOD

Cross-sectional survey of patients using treatment prescriptions and clinical records in two general practices from the west of Birmingham (serving a patient population of 16,519) where 4522 subjects (27.4%) were aged > or = 50 years.

RESULTS

One hundred and eleven (2.4%) patients who were aged > or = 50 years were found to be in AF (42 males; mean age 76.6, SD 9.1); 77.5% were Caucasian, 2.7% Afro-Caribbean, 0.9% Asian, and 0.9% mixed race; in 20 cases there was no information on ethnicity. Of the AF patients, 5.4% were aged 50-60 years, 16.2% aged 61-70 years, 20.7% aged 71-75 years, 20.7% aged 76-80 years, 24.3% aged 81-85 years, and 12.6% aged > 85 years old, with female patients being significantly older than males. Eighty-one patients (73%) had chronic AF, while 30 patients (27%) had paroxysmal AF. The most common associated factors were hypertension (36.9%) and ischaemic heart disease (28.8%), with no obvious cause for AF in six patients. Cardiac failure was associated with AF in 34 patients (30.6%), and stroke had occurred in 29 patients (18%). Only 20 patients (18%) had had an echocardiogram, 26 (23.4%) a chest X-ray, and 58 (52.3%) thyroid function test. Only 30.6% had ever presented to hospital practice. Warfarin was prescribed to 40 patients (36%), with anticoagulation intensity monitoring by the general practitioner (GP) in three cases (7.5%), by a hospital clinic in 30 (75%), and by both GP and hospital in seven cases (17.5%). Of those not anticoagulated (n = 71), only 12 patients (16.9%) had contraindications to warfarin therapy. Patients treated with warfarin were younger than those who were not prescribed warfarin (71.3 versus 79.6 years, P < 0.001). Aspirin was being prescribed for 21 patients (18.9%), primarily for previous myocardial infarction. Only five patients (4.5%) had ever had attempted cardioversion.

CONCLUSION

Atrial fibrillation is a common arrhythmia in general practice, and is commonly associated with hypertension, ischaemic heart disease and heart failure. There is a suboptimal application of standard investigations and use of antithrombotic therapy or attempted cardioversion; and few patients have presented to hospital practice. Guidelines on the management of this common arrhythmia in general practice are required.

Alteration of rat liver 20S proteasome activities by age and food restriction

The effects of age and food restriction on proteasome function in rat liver supernatant (100,000 x g) were investigated. The cellular level of the proteasome has been quantitated by using Western blot analysis. The level of the proteasome was not affected by either age or food restriction. The three best-characterized proteasomal peptidase activities, chymotrypsin-like (ChT-L), trypsin-like (T-L), and peptidylglutamyl peptide hydrolyzing (PGPH) activities, were measured in the presence and absence of the proteasomal activator, sodium dodecyl sulfate (SDS). Basal ChT-L, T-L, and PGPH activities were not markedly affected by either age or food restriction. SDS-stimulated ChT-L and T-L activities increased approximately 15% and approximately 30%, respectively, between 7 and 26 months of age, and the increase of both activities was prevented by food restriction. In marked contrast, the SDS-stimulated PGPH activity decreased approximately 40% with age. Food restriction, while not preventing the age-related decline, maintained higher levels of SDS-stimulated PGPH activity at all ages. The proteolytic activity of the proteasome toward casein was not altered by either age or food restriction. In conclusion, the cellular level of the proteasome as well as the caseinolytic activity of the proteasome appear to be unaffected by either age or food restriction. It appears unlikely that the proteasome activity changes are related to the reported age-associated decline of protein degradation. Simultaneously, proteasomal peptidase activities appear to be differentially regulated by both age and food restriction. It suggests more subtle age-related changes in proteasome function, which could include an effect on proteasomal subunit composition.

Stress and psychiatric disorder in the Hindu Kush: a community survey of mountain villages in Chitral, Pakistan

BACKGROUND

It is widely believed that people in remote areas of the world suffer less emotional distress and fewer psychiatric disorders. Previous studies offer contradictory evidence.

METHOD

First stage screening of two mountain villages in Chitral used the Bradford Somatic Inventory (BSI). Psychiatric interviews were conducted with stratified samples using the ICD10 Diagnostic Criteria for Research.

RESULTS

The BSI was an effective screening test, with sensitivity of 80% and specificity of 77%. At a conservative estimate, 46% of women and 15% of men suffered from anxiety and depressive disorders. Literate subjects had lower levels of emotional distress than the illiterate. Higher socio-economic status was associated with less emotional distress. Members of joint and nuclear families were similar.

CONCLUSIONS

The study offers no support for the belief that people who live in Chitral lead stress-free lives or have low rates of psychiatric morbidity. Women may suffer more anxiety and depressive disorders than in Western societies.

Contralateral inguinal hernial development and ipsilateral recurrence following unilateral hernial repair in infants and children

The aim of the present study was to evaluate the frequency of contralateral hernial development and ipsilateral recurrence following surgery for unilateral inguinal hernia in infants and children. During the period 1961-1970, 161 infants and children (143 males and 18 females; 0-12 years old) underwent surgery for unilateral inguinal hernia. The patients were followed for 20-29 years (until 1990). 16/143 males (11.2%), and 1/18 females developed a contralateral inguinal hernia; the frequency among patients less than seven years old was significantly higher than the frequency among older children (16/118 > 1/43; p < 0.05). No significant difference was observed between patients primarily operated for rightsided and leftsided hernias. Four/143 boys (2.7%) experienced testicular maldescens. Recurrence after herniotomy was seen in 9/143 males (6.3%), and in 1/18 females. The low frequency of contralateral hernial development, as the risk of surgical complications, indicate that routine contralateral inguinal exploration may not be recommended while operating upon unilateral symptomatic inguinal hernias. Our recurrence rate of 6.2% may mirror the conditions in a general surgical department, where several surgeons and residents operate upon a limited number of paediatric patients.

Indicators for antibiotic therapy in invasive bacteria diarrhoea

The objective of the study was to determine the clinical indications for antibiotic therapy in diarrhoeal diseases (DD) in 619 children aged 6 to 59 months who were evaluated during a clinical study of diarrhoea. The patients were seen at the outpatient clinic of the Palembang General Hospital from May 1991 through March 1992. Data concerning abdominal pain, pain during defecation, fever, status of breastfeeding, vomiting, mucoid stool, bloody stool, abdominal distention, stool leucocytes and erythrocytes were analyzed to determine their predictive value (PPV) in relation to the bacterial isolation of pathogen in the stool. All clinical variables examined had a low PPV for isolation of any enteric pathogen, including Shigella. The PPV of grossly bloody diarrhoea was 20.8% (95% confidence limits 17.6%-24%), and that of body temperature (> 37.5 degrees C) was 19.6%. When the stool leucocytes were 10 or more per high-power microscopic field (HPMF), the PPV was 22.2%; of erythrocytes found microscopically in the stool, 19.6%. We recommend that those patients with bloody stools and mucoid stools with temperatures of 37.5 degrees C get antibiotics (22%). Second, those patients having 10 or more leucocytes per HPMF plus those with red cells in stools (regardless of the number) should receive either antibiotics and or amoebicides if amoebae are present (5%).

Effect of gamma-interferon on the synthesis of the functional alternative and terminal complement pathways by human umbilical vein endothelial cells in vitro

The cytokine gamma-interferon (gIFN) has been reported to modulate synthesis by endothelial cells (EC) of alternative pathway complement factors (H, I, and B). However, the net effect of gIFN on the synthesis and expression of the functional alternative and terminal pathways has not yet been reported. EC cultured under serum-free conditions were treated with different concentrations of gIFN and simultaneously co-incubated with agarose beads, which activate the alternative pathway. C3b and the terminal complement complex (TCC) bound to co-incubated beads were measured by radioimmunoassay using anti-human C3c and TCC antibodies. gIFN in concentrations 500-4000 U/ml increasingly reduced the amount of C3b and TCC detected on the beads. The down-regulating effect of gIFN on EC complement biosynthesis may be physiologically relevant by locally controlling complement activation.

[Experience with the treatment of war injuries in Afghanistan]

The International Committee of the Red Cross surgical hospital for Afghan war-wounded is located across the border in Pakistan. The author describes experiences from his work in that hospital from July 1981 to November 1985. During the period, 6,700 patients were admitted to the hospital and 13,184 major and minor surgical operations were performed. In the case of persons wounded in guerilla warfare, when treatment is delayed due to poor transportation facilities, the accepted treatment for conventional battlefield injuries should not be applied without modification. The author discusses the principles for treating injuries to different organs.

Small bowel diverticulosis complicated by diverticulitis and paralytic ileus. Report of a case

Small bowel diverticulosis occurs in 0.3-4.4% of all autopsies. Generally the condition is clinically silent; but acute diverticulitis with peritonitis and paralytic ileus may occur in elderly people. This complication has a high mortality and its successful management requires early diagnosis and surgery.

Fetal supraventricular tachycardia and hydrops fetalis: combined intensive, direct, and transplacental therapy

A 25-week fetus with severe hydrops fetalis secondary to supraventricular tachycardia was treated with fetal intramuscular injections of digoxin in conjunction with maternal intravenous digoxin, followed by oral digoxin and subsequently by oral procainamide therapy. Fetal umbilical blood sampling revealed poor placental transfer of digoxin, even after 2 weeks of therapeutic maternal levels. This case suggests that direct fetal therapy is of value in the treatment of some fetuses with supraventricular tachycardia, and lends further evidence that the role of transplacental digoxin therapy is limited in the compromised fetus. It also demonstrates that resolution of hydrops may require a prolonged period.

The behaviour of health care providers in managing diarrheal disease in Palembang City, south Sumatera, Indonesia

A study on knowledge, attitude and practice of health care providers in Palembang had been conducted at the end of 1989 and beginning of 1990. Four approaches were carried out: (1) by recording the help obtained by cases who consulted researchers for further help for the same diarrheal diseases (DD) episode, (2) by studying the medical records of DD cases admitted to three hospitals, (3) by studying prescriptions dispensed by three pharmacies and (4) by focus group discussions. The findings were analysed to evaluate the achievement of the Indonesian Diarrheal Diseases Control Program (CDD). ORT, avoiding antimotility drugs and appropriated feeding have been accepted and practiced by the providers in Palembang. The target of promotion now is to support the acquisition of these behaviours to be implemented as a routine habit of the providers and as a part of the ongoing system of health care delivery system. Specifically the danger of loperamide promotion to the policy on antimotility must be stressed. Rapid iv rehydration and avoiding surface precipitating agents have been accepted, but are not practiced consistently yet due to practical considerations. It seems that there is no impact at all of CDD towards the rate of antibiotic therapy in DD. Besides intensifying the campaign, enforcing group pressure, may be we have to elaborate more the perception of health care provider as a practitioner, and conforming the strategy of the CDD campaign towards the findings. Health education had not been practiced effectively yet. Morale and value system of the providers are important for the success of this program. In general the medical-technic aspect of the CDD has been accepted by the providers, but there is still a lot to do in communicating them to be adopted as an effective behaviour.

[Morgagni Hernia]

The article describes a 65 year-old female with a 40 years' history of abdominal discomfort and a supposed intrathoracal lipoma who was admitted to hospital with acute obstruction of the large bowel. Emergency laparotomy revealed a subcostosternal diaphragmatic hernia (hernia of Morgagni) containing omentum and a segment of transverse colon.