The impact of social determinants on health outcomes in a region in the North of England: a structural equation modelling analysis

OBJECTIVES

The aim of this study was to identify the impact of social determinants of health on physical and mental health outcomes in a UK population.

STUDY DESIGN

Structural equation modelling was used to hypothesise a model of relationships between health determinants and outcomes within a region in the North of England using large-scale population survey data (6208 responses).

METHODS

We analysed responses from a population survey to assess the influence of a deprivation-based index at the environmental level, education and income on a behaviour index (smoking, alcohol consumption, physical activity, and dietary habits) and the influence of all these factors on self-reported physical health and the influence of the behaviour index and income on mental wellbeing.

RESULTS

The proposed model was well supported by the data. Goodness-of-fit statistics, most notably a low value of the root mean square error of approximation (RMSEA), supported the validity of the proposed relationships (RMSEA = 0.054). The model revealed all examined paths to be statistically significant. Income and education were influential in determining an individual's behaviour index score, which, with income was the most important predictor of both the correlated outcomes of physical health and mental wellbeing (P < 0.001 in all cases).

CONCLUSIONS

Findings challenge the traditional view of singular causal pathways, emphasising that interventions should consider the underlying influencing socio-economic conditions, which would influence behaviour and therefore physical and mental wellbeing. The extent to which the model is supported by the data, and the statistical significance of individual relationships accentuates the imperative for comprehensive public health strategies that integrate multiple socio-economic factors.

Risk factors for corneal ulcers: a population-based matched case-control study in Nepal

BACKGROUND/AIMS

We aimed to examine risk factors for corneal ulcer in a rural and peri-urban setting in Nepal.

METHODS

This population-based matched case-control study was nested in a cluster randomised trial in 24 village development committees in Nepal. Incidence density sampling was used to match incident corneal opacity cases to controls, matching on time of opacity, age, sex and location. Cases and controls were invited to participate in a survey of risk factors for corneal ulcer. Risk factors were evaluated using conditional logistic regression to account for matching.

RESULTS

Of the 540 participants with incident opacities identified in the trial, 433 were willing to participate in this substudy and matched to a control. Compared with controls, cases had lower odds of having any education vs no education (adjusted OR, aOR 0.60, 95% CI 0.39 to 0.94), working in non-manual labour occupations vs manual labour occupations (aOR 0.64, 95% CI 0.42 to 0.95) and preferring medical shops for ocular trauma versus eye care system centres (aOR 0.58, 95% CI 0.37 to 0.92). Cases had higher odds of protective goggle use versus no protection (aOR 3.8, 95% CI 1.3 to 11.0) and having an ocular injury vs none (aOR 7.7, 95% CI 4.3 to 13.6) compared with controls.

CONCLUSION

We found ocular injury, manual labour and lower education to be strongly associated with the development of corneal ulcer. Given the persistent burden of corneal blindness in this area, prevention efforts could target efforts to increase access to care in areas where these factors are common.

Relationship Between Intraocular Pressure and Age: A Population-Based Study in Nepal

PRCIS

Intraocular pressure (IOP) decreased with age in a population-based study in Nepal, from a mean of 14.1 mm Hg among those 60-64 years old to 13.0 mm Hg among those 80 years old or older.

PURPOSE

Few studies have assessed the distribution of IOP from the Indian subcontinent, despite its large population and high burden of glaucoma. The objective of this study was to assess the distribution of IOP measurements from adults living in a lowland region of Nepal.

METHODS

In a population-based cross-sectional study, all individuals aged 60 years and older from an area of lowland Nepal were invited for an IOP assessment with a rebound tonometer.

RESULTS

Of 160 communities (28,672 people aged ≥60 y) enrolled, 79 (13,808 people aged ≥60 y) were randomly selected for IOP testing. Of those eligible, 10,017 (72.5%) individuals underwent tonometry. Mean IOP decreased monotonically over 5-year age groups, from 14.1 mm Hg (SD: 3.6) among those aged 60-64 years to 13.0 mm Hg (SD: 4.2) among those 80 years or older. The 97.5th percentile IOP measurement was 21.0 mm Hg for all age groups. In adjusted analyses, younger age, self-reported diabetes, and higher population density were each associated with higher IOP, and self-reported cataract surgery was associated with lower IOP.

CONCLUSIONS

Mean IOP was lower among older individuals in Nepal, consistent with many studies from East Asia and in contrast to many studies from western populations. These results suggest that ethnic background might be a consideration when diagnosing ocular hypertension.

Clinical Characteristics of Patients with Glaucoma Presenting to Bharatpur Eye Hospital: An Observational Study

Introduction: Glaucoma is the second leading cause of blindness worldwide. Glaucoma will affect 79.6 million individuals by 2020, according to projections. Improved glaucoma screening and treatment approaches are urgently needed. The purpose of this study is to determine the clinical characteristics of glaucoma patients who visit Bharatpur Eye Hospital and aims to calculate the number of new diagnoses of glaucoma from 01 February 2020 to 15 March 2020.  Materials and methods: This is a hospital-based, cross-section study. All patients with a diagnosis of glaucoma were invited to participate. The examination findings, diagnosis, and management were all documented. A standardized questionnaire was used to collect patient knowledge and understanding of glaucoma. Results: Among 127 patients 52.8% were newly diagnosed with glaucoma. Many patients (59.8%) were symptomatic for more than 6 months. The mean presenting intraocular pressure was 20.86 mm Hg with an SD of 11.55 mm Hg. Only 44.9% of the participants had heard about glaucoma. Many participants (65.4%) did not have knowledge of glaucoma. Among 127 participants 9.4% had a family history of glaucoma. Conclusion: Glaucoma is a significant burden that presents challenges to ophthalmic services in Chitwan. Many people have a poor understanding of their condition and have limited access to services. There is a need to build a treatment infrastructure and raise public awareness.

Feasibility of laproscopic appendectomy in appendicities and appendicular perforation

Introduction: The advent and rapid acceptance of laparoscopic surgery led to the idea of performing laparoscopic  appendectomy (LA). In 1983 Semm, a German gynecologist performed the first LA. More than three decades later, the benefits of LA are still controversial. The objective of this study is to assess the feasibility of laproscopic appendectomy in appendicitis and appendicular perforation.Methods: Thirty five patient undergoing laproscopicappendectomy for appendicitis from 14th feb 2015 to 11th feb 2016 in Grande international hospital were included in the study. Duration of surgery, requirement of analgesia, time to normal diet and regular activity as well as length of hospital stay and postoperative complications were studied.Results: A total of 35 patients underwent laparoscopic appendectomy during the study period.Ten patients have peri-appendicular pus collection of which six patients have perforation. Median duration of surgery was 59±8.64 minutes.  Mean Post operative pain score was  4.71±0.71. Mean intravenous fevastin requirement was 3.31±0.9 gm and intravenous ketorolac  was 94±27mg while oral diclofenac was 731±172.81mg. Postoperative complications were 9%.  Mean time to normal diet resumption was 1.17±0.47 days and time to normal activities was 10.5±2.44 days. Median length of hospital stay was 1.9±0.96 days.Conclusion: Laproscopic appendectomy is a feasible option for appendicitis as well as appendicular perforation. More frequent use of this procedure may lead to reduction in operating time. Continuation of laproscopic appendectomy as a therapeutic option for patients with appendicitisas well as appendicular perforation need evaluation in large study scale.

Klippel-Trenaunay Syndrome: A Case Report

Klippel-Trenaunaysyndrome(KTS) is a rare congenital condition usually presenting with port wine stains, excessive growth of bones and soft tissue and varicose veins which most commonly occurs in the legs, but it also may affect the arms, face, head, or internal organs. We report a case of term male neonate with clinical findings of Port-wine stain, multiple cystic swellings with ultrasonographic findings suggestive of vascular malformations and limb abnormalities in the form ofsoft tissue hypertrophy of right upper limb, polydactyly of right hand and syndactyly of left hand consistent withKlippel-Trenaunay syndrome.

Burkhalter opponensplasty; role in isolated median nerve injury

OBJECTIVE

To report the outcome of Burkhalter opponensplasty using Extensor Indicis Proprius with isolated traumatic low median nerve palsy.

METHODS

The prospective study was conducted at the Mayo Hospital, Lahore, from June 2010 to June 2013, and comprised cases of Burkhalter opponensplasty using the Extensor Indicis Proprius to restore thumb opposition in isolated median nerve palsies. All patients had the condition for 16 to 20 months. The tendon was harvested just proximal to the extensor expansion and the insertion was to the distal attachment of abductor pollicis brevis.

RESULTS

Of the 11 patients in the study, 6(54.5%) were females and 5(45.5%) were males, with overall ages ranging between 19 years and 51 years. There were no postoperative complications. Nine (82%) patients had excellent results, while the remaining 2(18%) had good result.

CONCLUSIONS

In patients with isolated traumatic median nerve palsy, Burkhalter opponensplasty yielded excellent and satisfactory results.

Results of injection corticosteroids in treatment of De Quervain's Tenosynovitis

BACKGROUND

De Quervain's tenosynovitis is defined as stenosing tenosynovitis of the synovial sheath of tendons of abductor polices longus and extensor pollicis brevis in the first compartment of wrist due to repetitive use.

OBJECTIVE

To assess the results of injecting corticosteroids injections for De Quervain's tenosynovitis.

METHODS

80 patients with disease were included in this study. All had a mean of 5.87 weeks of treatment of the condition with NSAIDs and had shown no response. Using Visual analogue scale the severity of tenderness on first dorsal compartment and pain felt on Finkelstein test was recorded. A mixture of 1 ml (40mg) of methylprednisolone acetate and 1 ml of 2% lignocaine hydrochloride was injected in first dorsal compartment of involved wrist. Patients were followed for 28 weeks on monthly basis. Outcome measure was reduction in pain and tenderness on the radial side of wrist and negative Finkelstein test subsequent to injection.

RESULTS

65% patients after 1st injection were symptoms free at two weeks, 35% patients were given second injection two weeks after the first. 80% patients at four weeks, 95% patients at six weeks and 98.75% patients were symptom free at 12th week. One patient underwent surgical release. The adverse reaction of steroid was seen in 25% of patients, which were subsided in 20 weeks.

CONCLUSIONS

We conclude that two or three local steroid injections in the first dorsal compartment lead to significant improvement in patients with de Quervain's tenosynovitis.

Role of injecting bone marrow aspiration injection in treating delayed union and non-union

OBJECTIVE

To access the role of bone marrow injection in the management of delayed union and non-union.

METHODS

The prospective study was conducted at the Department of Orthopaedic Surgery and Traumatology, Mayo Hospital, Lahore, from January 2012 to December 2013, and comprised patients who had long bone fractures that resulted in delayed or non-union and were treated with bone marrow injections. Aspiration of bone marrow was done from tibial tuberosity and was injected percutaneously at the fracture site. The whole procedure was carried out as a day case. Fracture site mobility, tenderness and radiological features were assessed using the Union Scale score.

RESULTS

Of the 25 patients, 18(72%)were male and 7(28%) were female with an overall mean age of 38±12.96SD years (range: 17-61 years). There were 19(76%) tibial shaft fractures, 4(16%) had shaft of femur fracture, and 2(8%) had humeral shaft fracture. Mean time duration between the injury and the procedure was 34 ±3.46 SD weeks (range: 30-42 weeks). Overall, 23 (92%) patients showed union and the mean time of healing was 15 ±2.73SD weeks (range: 12-22 weeks) after the procedure.

CONCLUSIONS

Percutaneous bone marrow injection provided an alternative to open bone grafting, having least complications, especially for early intervention in the fracture-healing process.

Idiopathic cases of male infertility from a region in India show low incidence of Y-chromosome microdeletion

Chromosomal and Y-chromosomal microdeletion analysis has been done in cases of idiopathic infertility with the objective of evaluating the frequency of chromosomal and molecular anomaly as the causal factor of infertility. Barring a few cases of Klinefelter syndrome (XXY or XY/XXY mosaics), no chromosomal anomaly was encountered. Y-microdeletion was analysed by PCR-screening of STSs from different regions of the AZF (AZFa, AZFb, AZFc) on the long arm of the Y, as well as by using DNA probes of the genes RBM, DAZ (Yq), DAZLA (an autosomal homologue of DAZ) and SRY (Yp; sex determining gene). Out of 177 cases examined, 9 (azoospermia - 8 and oligoasthenospermia - 1) showed partial deletion of AZF. The size of deletion varied among patients but AZFc was either totally or partially removed in all of them. In contrast, no deletion was detected in AZFa. Testis biopsy done on a limited number of cases (50) showed diverse stages of spermatogenic arrest with no specific correlation with the genotype. The frequency of Y-chromosome microdeletion in our samples (approximately 5%) is much lower than the frequency (approximately 10%) reported globally and the two previous reports from India. We contend that the frequency may be affected by population structures in different geographical regions.

Significance of Qt Dispersion to Improve the Diagnostic Accuracy of Exercise Stress Tests for Myocardial Ischaemia

Background: This study consisted of 60 randomly selected patients (49 men and 11women) who had undergone both symptom-limited treadmill exercise tests andcoronary angiography, within one month, for clinical indications. This was a prospectivestudy done during the period of December 1998 to July 1999 in NICVD, DhakaBangladesh. The ECG is generally considered to provide a summation of the electricalactivity of the heart and to be insensitive to local electrophysiological events. Recentstudies suggest that important local electrophysiological differences can be detectedfrom a standard 12 -lead ECG, allowing new insights into the electrical behavior ofpatient’s hearts. The QT dispersion recorded as the difference between maximumand minimum QT intervals on a 12-lead ECG, is sensitive to myocardial ischaemiaand may improve the accuracy of exercise testing.Methods and Results: Exercise ECGs were analyzed in 60 patients who had undergoneexercise ECG and coronary angiography for clinical indications:1) The true-positive (TP) group consisted of 22 patients with mean ±SD age of 52 ± 9years. These patients had a positive treadmill test result with ³1 mm horizontal STsegmentdepression and an abnormal coronary angiogram, defined as ³ 50% diameterstenosis of a major epicardial coronary artery. Two patients were female in this group.2) The true negative (TN) group consisted of 20 patients who had a negative exercisetest and non significant CAD based on coronary angiography. The mean ± SD age ofthe group was 44 ± 8 years. Five patients were female in this group.3) Eight patients with positive treadmill test result with abnormal exercise ECGs andnon significant coronary artery disease (False positive [FP] group). This group had amean age of 43± 10 years. Three patients were female in this group.4) The false negative (FN) group consisted of 10 patients with mean ±SD age of 48± 7years. These patients had negative exercise ECG and an abnormal coronary angiogram.This group had one female patient.The exercise QTD Was 41±14ms in TN, 78±22ms in TP (P<0.001 versus TP) and47±16ms in FP (P=NS versus TN and P< 0.001 versus TP) groups. The exercise QTDwas 84±17ms in FN (P=NS versus TP) group.A stress QTD of >60ms had a sensitivity of 88% and specificity of 93% for the diagnosisof significant CAD compared with 68% (P<0.05) and 71% (P<0.01) respectively, for³ 1mm ST-segment depression during stress. When QTD of >60ms was added to STsegmentdepression as a condition for positive test, the specificity increased to 100%.Conclusion: Exercise QTD is an easily measurable ECG variable that significantlyincreases the accuracy of exercise testing.Key Words: QT dispersion . coronary disease . electrocardiography . exercise.