THE ROLE OF COENZYME COQ10 AND VITAMIN E IN PATIENTS WITH BETA-THALASSEMIA MAJOR IN BAGHDAD CITY POPULATION

Our study aimed to evaluate the level of coenzyme (CoQ10) in the plasma of human which suffered from beta-thalassemic major disease and vitamin E concentration in comparison to control cases. We included 90 (60 β-TM patients and 30 persons for control groups). The range of age (15-40 years) during the period from December 2022 to March 2023, and the study included patients previously diagnosed with beta-thalassemia major from Medical City and Karama Hospital. The level of serum CoQ10 in the patients was 2.02 ng/ml and in the control, groups were 3.55 ng/ml. The difference was statically high between the two groups (P<0.001). Likewise, our study includes the concentration of vitamin E in the study groups (patients 2.29 ng/ml and for control cases 7.25 ng/ml). The results highlight that there was a highly significant difference between the two groups (P<0.001). In conclusion, for both β-TM patients and control groups, the results show that the two parameters CoQ10 and vitamin E were highly significant difference((P<0.001) which means there were lower antioxidant capacities as demonstrated by the results of our new study.

Making voluntary medical male circumcision services sustainable: Findings from Kenya's pilot models, baseline and year 1

Voluntary medical male circumcision is a crucial HIV prevention program for men in sub-Saharan Africa. Kenya is one of the first countries to achieve high population coverage and seek to transition the program to a more sustainable structure designed to maintain coverage while making all aspects of service provision domestically owned and implemented. Using pre-defined metrics, we created and evaluated three models of circumcision service delivery (static, mobile and mixed) to identify which had potential for sustaining high circumcision coverage among 10-14-year-olds group, a historically high-demand and accessible age group, at the lowest possible cost. We implemented each model in two distinct geographic areas, one in Siaya and the other in Migori county, and assessed multiple aspects of each model's sustainability. These included numerical achievements against targets designed to reach 80% coverage over two years; quantitative expenditure outcomes including unit expenditure plus its primary drivers; and qualitative community perception of program quality and sustainability based on Likert scale. Outcome values at baseline were compared with those for year one of model implementation using bivariate linear regression, unpaired t-tests and Wilcoxon rank tests as appropriate. Across models, numerical target achievement ranged from 45-140%, with the mixed models performing best in both counties. Unit expenditures varied from approximately $57 in both countries at baseline to $44-$124 in year 1, with the lowest values in the mixed and static models. Mean key informant perception scores generally rose significantly from baseline to year 1, with a notable drop in the area of community engagement. Consistently low scores were in the aspects of domestic financing for service provision. Sustainability-focused circumcision service delivery models can successfully achieve target volumes at lower unit expenditures than existing models, but strategies for domestic financing remain a crucial challenge to address for long-term maintenance of the program.

Rollout of ShangRing circumcision with active surveillance for adverse events and monitoring for uptake in Kenya

INTRODUCTION

Since 2011, Kenya has been evaluating ShangRing device for use in its voluntary medical male circumcision (VMMC) program according to World Health Organization (WHO) guidelines. Compared to conventional surgical circumcision, the ShangRing procedure is shorter, does not require suturing and gives better cosmetic outcomes. After a pilot evaluation of ShangRing in 2011, Kenya conducted an active surveillance for adverse events associated with its use from 2016-2018 to further assess its safety, uptake and to identify any operational bottlenecks to its widespread use based on data from a larger pool of procedures in routine health care settings.

METHODS

From December 2017 to August 2018, HIV-negative VMMC clients aged 13 years or older seeking VMMC at six sites across five counties in Kenya were offered ShangRing under injectable local anesthetic as an alternative to conventional surgical circumcision. Providers described both procedures to clients before letting them make a choice. Outcome measures recorded for clients who chose ShangRing included the proportions who were clinically eligible, had successful device placement, experienced adverse events (AEs), or failed to return for device removal. Clients failing to return for follow up were sought through phone calls, text messages or home visits to ensure removal and complete information on adverse events.

RESULTS

Out of 3,692 eligible clients 1,079 (29.2%) chose ShangRing; of these, 11 (1.0%) were excluded due to ongoing clinical conditions, 17 (1.6%) underwent conventional surgery due to lack of appropriate device size at the time of the procedure, 97.3% (1051/1079) had ShangRing placement. Uptake of ShangRing varied from 11% to 97% across different sites. There was one severe AE, a failed ShangRing placement (0.1%) managed by conventional wound suturing, plus two moderate AEs (0.2%), post removal wound dehiscence and bleeding, that resolved without sequelae. The overall AE rate was 0.3%. All clients returned for device removal from fifth to eleventh day after placement.

CONCLUSION

ShangRing circumcision is effective and safe in the Kenyan context but its uptake varies widely in different settings. It should be rolled out under programmatic implementation for eligible males to take advantage of its unique benefits and the freedom of choice beyond conventional surgical MMC. Public education on its availability and unique advantages is necessary to optimize its uptake and to actualize the benefit of its inclusion in VMMC programs.

Influenza Immunizations in the Elderly: A Continuous Quality Improvement Project

As part of the continuous quality improvement program at The Toronto Hospital’s Department of Family & Community Medicine (TTH-DFCM), it was considered necessary to examine the structures, processes and outcomes of influenza immunization for the elderly. Objective: The study sought to (a) document the current influenza immunization process; (b) quantify influenza immunization rates for elderly patients during two consecutive immunization seasons (1996 and 1997), and compare these rates across physician teams, attending staff vs. residents, patient gender, and patient age groups; (c) compare influenza immunization rates with other centers; and (d) identify barriers and propose solutions to improve influenza immunization rates in the elderly. Design: Evaluation Formative Research. Setting: A computerized roster of 15,000 patients at The Toronto Hospital, Department of Family and Community Medicine, a University of Toronto academic teaching center. Participants: Active patients age 65 years and over. Dependent variable: Influenza immunization. Independent variables: Physician Teams, Physician status, Patient gender, and Patient age group. Results: Immunization rates of attendees increased from 75.4% to 78.7%; over 3% increase from 1996 to 1997. Major subgroups which benefited from increased immunization rates were patients in the Blue team, patients age 70-74 years, and female patients. Conclusion: This study presents a rigorous examination of the components of the influenza immunization program, and demonstrates improved immunization rates over a two-year period. Suggestions for future action have been identified. The study design can also serve as a model for future clinical quality improvement projects.

Developing a mHealth intervention to promote uptake of HIV testing among African communities in the UK: a qualitative study

BACKGROUND

HIV-related mHealth interventions have demonstrable efficacy in supporting treatment adherence, although the evidence base for promoting HIV testing is inconclusive. Progress is constrained by a limited understanding of processes used to develop interventions and weak theoretical underpinnings. This paper describes a research project that informed the development of a theory-based mHealth intervention to promote HIV testing amongst city-dwelling African communities in the conditions.

METHODS

A community-based participatory social marketing design was adopted. Six focus groups (48 participants in total) were undertaken and analysed using a thematic framework approach, guided by constructs from the Health Belief Model. Key themes were incorporated into a set of text messages, which were pre-tested and refined.

RESULTS

The focus groups identified a relatively low perception of HIV risk, especially amongst men, and a range of social and structural barriers to HIV testing. In terms of self-efficacy around HIV testing, respondents highlighted a need for communities and professionals to work together to build a context of trust through co-location in, and co-involvement of, local communities which would in turn enhance confidence in, and support for, HIV testing activities of health professionals. Findings suggested that messages should: avoid an exclusive focus on HIV, be tailored and personalised, come from a trusted source, allay fears and focus on support and health benefits.

CONCLUSIONS

HIV remains a stigmatized and de-prioritized issue within African migrant communities in the UK, posing barriers to HIV testing initiatives. A community-based participatory social marketing design can be successfully used to develop a culturally appropriate text messaging HIV intervention. Key challenges involved turning community research recommendations into brief text messages of only 160 characters. The intervention needs to be evaluated in a randomized control trial. Future research should explore the application of the processes and methodologies described in this paper within other communities.

Using marker pens on patients: a potential source of cross infection with MRSA

INTRODUCTION

Marker pens are widely used in surgery but pre-operative marking of patients may be a cause of bacterial cross-infection.

PATIENTS AND METHODS

Two experiments were performed to assess whether marking pens can be cause of cross-infection: (i) 26 indelible marker pens were collected from surgical wards for analysis; and (ii) 'fresh' as well as 'dry' (artificially dried by removing cap and exposing tip for 2 h) new permanent marker pens, and whiteboard marker pens were inoculated by dipping the tips into various concentrations of methicillin-resistant Staphylococcus aureus (MRSA). Each pen was inoculated onto 2 blood agar plates at 0 (immediately after inoculation) to 30 min at various intervals, 4 h and 24 h. The plates were incubated for 18 h at 35 degrees C in an incubator.

RESULTS

Of 26 pens collected from the wards, 2 cultured Micrococci spp. (skin commensals). The constituents of new 'fresh' pen tips rapidly kill MRSA - in all cases by 4 h, but usually within minutes. At high inoculum concentrations, MRSA is not killed immediately. Dry marker pens harbour MRSA for at least 30 min and probably longer.

CONCLUSIONS

Marker pens can act as fomites for nosocomial infection. The ethanol-based ink in permanent marker pens has a bactericidal action against MRSA that starts within seconds, and they are likely to be safe to use with a gap of at least 2 min between patients. Usually, harmless skin commensals are not pathogenic except in immunocompromised patients. Old or dried-out marker pens can harbour pathogens and should be discarded before attempted use on patients. We recommend disposable markers for the immunocompromised and patients with a known positive MRSA status.

A comparison of the views of patients and medical staff in relation to the process of informed consent

INTRODUCTION

The quality and quantity of information required in the consent process is well documented, but there is little extant literature regarding timing of either information about the proposed procedure or the act of consent itself. With the recent introduction of a new NHS-wide consent form, we wished to determine the preferences of both patients and staff to ascertain whether any concordance of views existed.

PATIENTS AND METHODS

A 10-point questionnaire, developed in conjunction with the department of clinical psychology was completed by 242 patients selected for surgery over a 4-month period. Identical questionnaires were completed by local staff (n = 50) and national consultant plastic surgeons (n = 56).

RESULTS

The cumulative majority (61.8%) preferred information at the specialist out-patient appointment (OPA). There was a significant difference (P < 0.001) between patients and staff as to information provision by the specialist as compared to non-specialists; staff indicating it much more strongly. As to the timing of consent form signature, 40.2% preferred signature on admission with no statistically significant difference between subgroups. An additional pre-operative clinic, for consent form signing, was selected by 27.3%. Staff expressed this view more often than patients (P < 0.001).

CONCLUSIONS

Patients prefer information about a planned surgical procedure at their specialist OPA and final consent for surgery when admitted to the ward. Staff had quite definite views and felt an additional pre-operative out-patient appointment to be beneficial, more so than the patients themselves.

Patterns of reinnervation and blood flow in split-skin grafts

One of the most important functions of skin is thermoregulation. The alterations in the patterns of blood flow in skin is one of the main physiological processes responsible for thermoregulatory control. The mechanisms governing the thermoregulatory control of cutaneous blood flow are mainly neural and chemical in nature. At present, there is a lack of studies in the literature looking at the relationship between reinnervation and the blood flow pattern of skin grafts. The present study uses Laser Doppler flowmetry and the immunohistochemical stains protein gene product 9.5, calcitonin gene-related peptide and substance P to identify nerve fibres, and antibodies to CD31 and von Willebrand factor to identify endothelial tissues. The aim of the present study was to investigate the patterns of blood flow and nerve tissue regeneration in split-skin grafts up to 15 years following the original procedure. Thirty-two split-skin grafts were studied and these were placed into two groups based on the nature of the bed of excision: group I consisted of patients who underwent tangential excision and split-skin grafting (n=17), and group II consisted of patients with split-skin grafts placed onto fascial beds (n=15). Each subpopulation of patients was further divided into three groups based on the length of time following grafting: one to three years, four to six years and seven to 15 years. These divisions were arbitrarily chosen and called A1, A2 and A3, respectively. In the Laser Doppler flowmetry arm of the study, the grafts were assessed at various stages after heating, cooling and further reheating. The Laser Doppler flowmetry studies showed that, on subjecting the skin grafts in both groups I and II to heating and cooling followed by reheating, the overall response of the blood flow to changes in the temperature was slower. The immunohistochemical analysis showed that in all graft types and graft ages, protein gene product 9.5, calcitonin gene-related peptide and substance P stains demonstrated a relative lack of the presence of nerve fibres in the split-skin grafts compared with the control ('normal' skin). However, von Willebrand factor and CD31 immunological staining demonstrated that vessels were present in the split-skin grafts, with no significant difference in size or quantity from the control samples. It was found that the blood flow in the split-skin graft in response to thermal challenge, although present, was slower than that of normal skin, a finding which was independent of the age of the skin graft. It is thought that this was related to a lack of regeneration of nerve fibres and, hence, a deficiency in the neurally mediated reflexes of the blood vessels within the split-skin grafts.

Patterns of sensory and autonomic reinnervation of long-standing myocutaneous microvascular flaps and split-skin grafts applied to fascial beds

BACKGROUND

There is a paucity of reports in the literature examining the pattern of sensory and autonomic neural recovery of myocutaneous microvascular flaps and skin grafts to the lower limbs after a prolonged period of time.

OBJECTIVES

To investigate the recovery of sensation and autonomic nerve activity in long-standing split-skin grafts applied to fascial beds and in myocutaneous microvascular flaps.

METHODS

THE PATIENTS WERE DIVIDED INTO TWO GROUPS: group A consisted of patients with a split-skin graft applied to a fascial bed (n=11) and group B consisted of patients with free microvascular flaps (n=4). Patients in both groups underwent various clinical subjective and objective tests, including the measurement of electrical resistance and thermal sensory analysis. Laser Doppler flowmetry was used to investigate the blood flow patterns.

RESULTS

Patients in both groups showed significantly reduced sensory modalities. However, the findings of both the electrical resistance and laser Doppler flowmetry were significantly different among the patients in group A compared with controls. In contrast, electrical resistance and laser Doppler flowmetry test results were similar in group B and controls.

CONCLUSIONS

Both split-skin grafts applied to fascial beds and microvascular flaps on the lower limb had poor sensory recovery. However, after 15 years, the microvascular flaps regained the ability to sweat and some degree of thermoregulatory function. This may imply that the long-standing myocutaneous free flaps regained some aspects of their autonomic innervation, whereas the split-skin grafts had not.

Influenza immunizations in the elderly: a continuous quality improvement project

As part of the continuous quality improvement program at The Toronto Hospital's Department of Family & Community Medicine (TTH-DFCM), it was considered necessary to examine the structures, processes and outcomes of influenza immunization for the elderly.

OBJECTIVE

The study sought to (a) document the current influenza immunization process; (b) quantify influenza immunization rates for elderly patients during two consecutive immunization seasons (1996 and 1997), and compare these rates across physician teams, attending staff vs. residents, patient gender, and patient age groups; (c) compare influenza immunization rates with other centers; and (d) identify barriers and propose solutions to improve influenza immunization rates in the elderly.

DESIGN

Evaluation Formative Research.

SETTING

A computerized roster of 15,000 patients at The Toronto Hospital, Department of Family and Community Medicine, a University of Toronto academic teaching center.

PARTICIPANTS

Active patients age 65 years and over.

DEPENDENT VARIABLE

Influenza immunization.

INDEPENDENT VARIABLES

Physician Teams, Physician status, Patient gender, and Patient age group.

RESULTS

Immunization rates of attendees increased from 75.4% to 78.7%; over 3% increase from 1996 to 1997. Major subgroups which benefited from increased immunization rates were patients in the Blue team, patients age 70-74 years, and female patients.

CONCLUSION

This study presents a rigorous examination of the components of the influenza immunization program, and demonstrates improved immunization rates over a two-year period. Suggestions for future action have been identified. The study design can also serve as a model for future clinical quality improvement projects.

Metabolic fates in humans of linamarin in cassava flour ingested as stiff porridge

Insufficiently processed products from cassava roots may contain residual amounts of cyanogenic glucosides, mainly linamarin. The fate of orally ingested linamarin was studied following a meal of cassava porridge prepared from cassava flour from southern Tanzania with 82 mg cyanide equivalents (3035 micromol) of linamarin per kg dry weight. Following ingestion of amounts of porridge containing 243-571 micromol linamarin by 15 healthy adults a mean (range) of 21% (1-47%) of the linamarin ingested was excreted in the urine within 24 hours and a mean of 1% in the next 24 hours. Serum thiocyanate, the main cyanide metabolite, increased in all subjects from a mean (+/-SD) of 34+/-26 to 78+/-28 micromol/litre (P < 0.001). In a second group of seven subjects we found that the ingestion of porridge with a mean (range) of 431 micromol (203-669%) of linamarin resulted in a mean linamarin excretion of 127 micromol/litre and an excess thiocyanate excretion of 118 micromol/litre and that 216 micromol was unaccounted for. We conclude that less than one-half of orally ingested linamarin is converted to cyanide and hence thiocyanate, about one-quarter is excreted unchanged and another quarter is metabolized into an as yet unknown compound.

Phialophora richardsiae endocarditis of aortic and mitral valves in a diabetic man with a porcine mitral valve

We report a case of Phialophora richardsiae endocarditis involving the aortic and a porcine mitral valve in a 52-year-old non-insulin dependent diabetic. Mitral valve replacement had been performed 4 years earlier. We believe this to be the first case of Phialophora richardsiae endocarditis to be reported.

Broncho-oesophageal fistula treated effectively without surgical resection

A patient with an oesophagobronchial fistula who was unfit for surgery was treated successfully by the application of sclerosants (sodium hydroxide and acetic acid) to the oesophageal and bronchial ostia of the fistula.