Surgical and non-surgical treatment of inguinal hernia during non-elective admissions in the Nationwide Readmissions Database

INTRODUCTION

Inguinal hernia repair is one of the most common surgical operations, yet the optimal treatment strategy remains undefined. Treatment of symptomatic inguinal hernias include both surgical and non-surgical approaches. The objective of this study was to determine differences in population, readmission rates, and costs between operative and non-operative approaches for patients admitted non-electively for an inguinal hernia in a national dataset. In addition, we sought to define the baseline characteristics of the two groups and identify potential predictive factors in the non-surgically managed subgroup who were readmitted and treated operatively within 90 days of their first visit.

METHODS

This study was a retrospective review of data from the Nationwide Readmissions Database (NRD) from 2010 to 2014. Patients above age 18 who were admitted non-electively for a primary diagnosis of inguinal hernia were included. Patients whose length of stay was < 1% or > 95% percentile or died during the initial visit were excluded. Readmissions within 90 days of the initial visit were flagged. Patients were classified according to initial management strategy: operative versus non-operative. Demographic, clinical, and organizational characteristics were compared between the two cohorts.

RESULTS

14,249 patients met inclusion criteria and were operative (n = 8996, 63.13%) and non-operative (n = 5255, 36.88%) cohorts. When comparing the two groups, readmission rate was lower (0.49% for surgical, 1.78% for non-surgical, p < 0.01), mean length of stay (LOS) longer (3.27 [SE = 0.05] days for surgical, 2.76 days [SE = 0.06] for non-surgical, p < 0.01), and mean total cost higher ($9597 for surgical, $7167 for non-surgical, p < 0.01) in surgically treated patients. The non-surgical population was on average older (63.05 years for surgical, 64.52 years for non-surgical, p < 0.01) with more chronic conditions (3.57 for surgical, 4.05 for non-surgical, p < 0.01). Of the patients initially managed non-surgically, 1.78% (n = 91) were readmitted, and of them, 62.63% (n = 57) were readmitted and managed surgically within 90 days of initial admission (i.e., crossed over from watchful waiting to surgical treatment). Average number of chronic conditions (3.79 versus 4.03, p = 0.74), average number of comorbidities (2.26 versus 2.18, p = 0.87), and average total number of ICD-9 discharge codes (7.44 versus 8.23 p = 0.54 did not differ significantly between the operative versus non-operative sample of the readmitted population. The total cost ($5562.38 versus $8737.28, p = 0.01) was greater in the operative versus non-operative sample.

CONCLUSION

Watchful-waiting strategy is the most common treatment approach in patients admitted non-electively for symptomatic inguinal hernia. Readmission after non-elective hospitalization for inguinal hernia is rare, but surgical intervention decreased the likelihood of readmission compared to non-operative management, while also increasing LOS and cost of care. Our data supports a patient centric approach to the management; non-surgical treatment is a viable temporary option even in symptomatic inguinal hernias, while surgical treatment may reduce the likelihood of future readmission.

Age at menopause, and knowledge of and attitudes to menopause, of women in Karachi, Pakistan

Objectives. The objectives of the study were to identify the average age at menopause in Karachi and to assess knowledge of and attitudes to the menopause among Pakistani women in different social strata.

Study design. A population-based cross-sectional study of 960 women aged over 35 years was conducted.

Results. As insufficient data were available for 35 women, 925 interviews were analysed. There were 287 menopausal women, whose mean (SD) age at menopause was 47.1 (4.7) years (95% CI 46.8 to 47.6). Of these 287 women, 135 (47%) wanted their menses to continue and 235 (82%) had consulted a physician after the menopause. Of all 925 women, 58% knew the correct definition of the menopause, all had consulted a physician for various symptoms related to the menopause and 53% said that women should consult a physician premenopausally. Symptoms experienced by premenopausal women included lack of sleep (25%), fear of infertility (13%) and urinary incontinence (18%). The majority of the overall sample (52%) were sexually active. Of the sexually active women, 16% had marital problems, compared with 44% of sexually inactive women, and this difference was statistically significant ( P < 0.0001). Source of knowledge about the menopause included relatives (35%), television (18%), neighbours (17%), friends (17%) and health-care providers (14%).

Conclusions. Evidence-based information about the menopause should be provided for Pakistani women.

Effects of calcium soap of rice bran oil fatty acids supplementation alone and with DL-α-tocopherol acetate in lamb diets on performance, digestibility, ruminal parameters and meat quality

Thirty-six Malpura lambs (28 day old and 6.7 ± 0.25 kg BW) were distributed equally in three groups having six males and six female. They were ad libitum fed individually three different experimental diets containing calcium soap of fatty acids (CA-FA) at 0 (T1 ) and 40 (T2 and T3 ) g/kg concentrate up to six months of age. Animals in T3 were supplemented additionally with 40 mg DL-α-tocopherol acetate/kg of concentrate. The roughage moiety included ad libitum dry Prosopis cineraria and fresh Azadirachata indica leaves. All the lambs were allowed to suckle from their dam up to weaning (90 day of age). Supplementation of Ca-FA improved weight gain and feed conversion ratio during both pre- (28-90 days) and post-weaning (91-180 days) phases; however, no effect of DL-α-tocopherol was observed. Metabolic parameters during post-weaning phase revealed non-significant effect on digestibility but improved nitrogen balance in the test groups. The effect on biochemical attributes did not show any significant alteration in ruminal parameters, blood biochemicals and urinary purine derivatives. Carcass traits revealed higher (p < 0.05) dressing yield and loin eye area with Ca-FA supplementation. The value of thiobarbituric reactive substances for nuggets prepared from frozen carcasses revealed significant (p < 0.05) reduction in T3 compared to the other dietary groups. Fatty acid profile of adipose tissue revealed higher (p < 0.001) 9-octadecanoic, 9-12-octadecadienoic, polyunsaturated fatty acids (PUFA), higher ratio of PUFA/saturated fatty acids (SFA), ω-6/ω-3 and lower SFA in Ca-FA-supplemented groups. It is concluded that supplementation of 40 g/kg calcium soap prepared from industrial grade rice bran oil in lamb ration provided additional energy intake, improved N utilization, gain and feed conversion ratio besides improving dressing yield and meat quality with CLA enriched fatty acid profile. DL-α-tocopherol acetate when supplemented at 40 mg/kg feed reduced lipid oxidation of meat products thus improving its keeping quality.

Microbicides and their potential as a catalyst for multipurpose sexual and reproductive health technologies

There is an urgent need for technologies to prevent sexual acquisition of HIV infection in young women in sub-Saharan Africa. After two decades of 11 pivotal trials of seven products, anti-retroviral-based topical microbicides are showing promise. Building on the CAPRISA 004 trial findings, several trials of new anti-viral agents, novel delivery mechanisms and combination/multipurpose products that address challenges of adherence and meet the sexual and reproductive health needs of men and women, including preventing HIV infection, are underway.

Growth performance of lambs fed diet supplemented with rice bran oil as such or as calcium soap

Forty two Malpura lambs (21 d old) were divided into three groups of 14 each consisting of 8 females and 6 males. Lambs were allowed to suckle their respective dams twice daily up to weaning (13 wks) and offered free choice concentrate and roughage in a cafeteria system. The lambs in control group were fed conventional concentrate mixture, in RBO group concentrate mixture fortified with 4% industrial grade rice bran oil and in Ca-soap rice bran oil (as in RBO group) was supplemented in the form of calcium soap. The concentrate intake decreased(p≤0.05) in RBO group as a result total dry matter, crude protein and metabolizable energy intake decreased compared to control whereas Ca-soap prepared from the same rice bran oil stimulated the concentrate intake leading to higher total dry matter, crude protein and energy intakes. The digestibility of dry matter (p≤0.05), organic matter (p≤0.05) and crude protein (p≤0.05) was higher in RBO group followed by Ca-soap and control whereas no effect was observed for ether extract digestibility. Higher cholesterol (p≤0.05) content was recorded in serum of oil supplemented groups (RBO and Ca-soap) while no effect was recorded for other blood parameters. Rice bran oil as such adversely affected and reduced the body weight gain (p≤0.001) of lambs in comparison to control whereas the Ca-soap of rice bran oil improved body weight gain and feed conversion efficiency in lambs. Fat supplementation decreased total volatile fatty acids (p≤0.05) and individual volatile fatty acid concentration which increased at 4 h post feeding. Fat supplementation also reduced (p≤0.05) total protozoa count. Ca-soap of rice bran oil improved pre slaughter weight (p≤0.05) and hot carcass weight (p≤0.05). It is concluded from the study that rice bran oil in the form of calcium soap at 40 g/kg of concentrate improved growth, feed conversion efficiency and carcass quality as compared to rice bran oil as such and control groups.

Mutant p53 enhances MET trafficking and signalling to drive cell scattering and invasion

Tumour-derived mutant p53 proteins promote invasion, in part, by enhancing Rab coupling protein (RCP)-dependent receptor recycling. Here we identified MET as an RCP-binding protein and showed that mutant p53 promoted MET recycling. Mutant p53-expressing cells were more sensitive to hepatocyte growth factor, the ligand for MET, leading to enhanced MET signalling, invasion and cell scattering that was dependent on both MET and RCP. In cells expressing the p53 family member TAp63, inhibition of TAp63 also lead to cell scattering and MET-dependent invasion. However, in cells that express very low levels of TAp63, the ability of mutant p53 to promote MET-dependent cell scattering was independent of TAp63. Taken together, our data show that mutant p53 can enhance MET signalling to promote cell scattering and invasion through both TAp63-dependent and -independent mechanisms. MET has a predominant role in metastatic progression and the identification of mechanisms through which mutations in p53 can drive MET signalling may help to identify and direct therapy.

Effect of concentrate supplementation on performance, ovarian response, and some biochemical profile of Malpura ewes

Effect of feed flushing on ovulation rate was investigated during the autumn seasons on 24 adult Malpura ewes (BW 34.8 ± 0.58 kg and age 4-7 years) equally divided into two groups. Ewes in G1 (group 1) were grazed 8-10 h daily on Cenchrus ciliaris pasture interspersed with seasonal shrub. In addition to grazing, concentrate was provided at 1.5% of BW to the animals in G2 (group 2) for a period of 35 days. Estrus was synchronized by a double injection schedule of PGF(2α) at 0 and 10 days of the experiment and detected by parading aproned rams at 6 h intervals. Blood samples were collected at weekly interval during the estrous cycle. A rumen fermentation study was conducted on day 23 of the experiment at 0 and 4 h post-concentrate feeding. Ovarian responses in terms of number of corpora lutea and large follicles was examined on all the ewes by laparoscopy after 3 to 6 days of each estrus and were found to be similar in both the groups. Hemoglobin and packed cell volume, total protein, albumin, and globulin were similar among the groups. Concentration of plasma glucose (12 and 22 days) was higher (P < 0.05) in G2 vis-à-vis control. Plasma urea was higher (P < 0.01) in the control than G2. Rumen liquor pH, concentration of total N, TCA-ppt N, NH(3)-N, and TVFA were significantly higher (P < 0.01) in G2 than the control. Thus, it can be concluded that concentrate supplementation in ewes prior to mating (flushing) did not enhance ovulation response during the autumn season.

Adaptive changes in HIV-1 subtype C proteins during early infection are driven by changes in HLA-associated immune pressure

It is unresolved whether recently transmitted human immunodeficiency viruses (HIV) have genetic features that specifically favour their transmissibility. To identify potential "transmission signatures", we compared 20 full-length HIV-1 subtype C genomes from primary infections, with 66 sampled from ethnically and geographically matched individuals with chronic infections. Controlling for recombination and phylogenetic relatedness, we identified 39 sites at which amino acid frequency spectra differed significantly between groups. These sites were predominantly located within Env, Pol and Gag (14/39, 9/39 and 6/39 respectively) and were significantly clustered (33/39) within known immunoreactive peptides. Within 6 months of infection, we detected reversion-to-consensus mutations at 14 sites and potential CTL escape mutations at seven. Here we provide evidence that frequent reversion mutations probably allows the virus to recover replicative fitness which, together with immune escape driven by the HLA alleles of the new hosts, differentiate sequences from chronic infections from those sampled shortly after transmission.

Effect of different feeding regimes on pre-weaning growth rumen fermentation and its influence on post-weaning performance of lambs

Influence of pre-weaning live weight on post-weaning growth performance was assessed on thirty-nine 15-day-old Indian native lambs, randomly fed in three equal groups until 180 days of age. During pre-weaning phase lambs were maintained under feeding regimen of grazing (C-0; Control), grazing and ad lib creep mixture supplementation (C-AL) or grazing, with ad lib creep mixture and milk replacer supplementation (C-ALMR). Lambs were allowed to suckle respective dam in morning and evening till 90 days of age, and fed ad lib green leaves of Ailanthus excelsa after grazing. After weaning all lambs were maintained on grazing and ad lib finisher concentrates supplementation. Pre-weaning performance of lambs in terms of weaning weight (17.2 kg), average daily gain (ADG; 154 g) and feed conversion ratio 3.73 was higher (p < 0.01) in C-ALMR lambs but total gain and ADG were similar among three groups during post-weaning phase. However, improved pre-weaning plane of nutrition and growth rate increased (p < 0.01) finishing weight (FW) of lambs in C-AL, 33 kg and C-ALMR, 32 kg. Dry matter intake was significantly (p < 0.01) higher in C-AL and C-ALMR lambs due to combined effect of feeding. Rumen pH was lowest (p = 0.049) in C-AL lambs. Rumen ciliate protozoa population (10(4)/ml) decreased in C-ALMR lambs (4.3) but increased in C-AL lambs (50.0) more so in C-0 Lambs (19.8). Concentrate feeding of C-AL lamb improved nutrient digestibility. Lambs of C-0 group consumed more DM during post-weaning phase that improved growth performance, while nutrient digestibility was not affected by pre-weaning nutrition. Thus, pre-weaning nutrition has significant influence on FW, however influence of milk replacer feeding on lamb growth need further studies.

Growth, haematology, blood constituents and immunological status of lambs fed graded levels of animal feed grade damaged wheat as substitute of maize

The aim of this study was to explore possibilities of utilization of animal feed grade damaged wheat (ADW) in lamb feeding, and assess the effect of ADW and its aflatoxin on intake, growth, haematology, blood biochemical constituents and immunological status. The ADW is a slightly mouldy feed resource, which is not suitable for human consumption. The experimental ADW contained dry matter (DM) 964, organic matter 974, crude protein 153, cellulose 205 and lignin 24, and starch 732 g/kg DM. ADW also contained aflatoxin B1 50 microg/kg due to mould infestation. Thirty-five weaner lambs (90 +/- 15 days of age and 16.1 +/- 0.82 kg body weight) in a randomized design were fed for 91 days on one of four composite feed mixtures (roughage to concentrate ratio of 25:75) containing 0, 118, 235, 353 or 470 g/kg ADW, which replaced equal amounts of maize and at these inclusion levels ADW replaced 0%, 25%, 50%, 75% and 100% maize in lamb diets respectively. Dry matter intake (DMI) was similar in different level of ADW fed lambs but ADW inclusion linearly (p = 0.016) reduced DMI. Average daily gain (g/day) was higher (p = 0.038) in lambs fed 353 g ADW diet. Haematological attributes viz. WBC, haemoglobin (Hb) and mean corpuscular volume did not affect by ADW feeding whereas it increased haematocrit, mean cell Hb and decreased neutrophil, RBC counts and mean cell Hb concentration. Blood glucose and urea-N increased whereas albumin and protein level reduced by ADW feeding. ADW feeding of lambs did not affect serum IgG level. The activities of serum aspartate aminotransferase, alkaline phosphates and acid phosphates were not affected, whereas alanine aminotransferase increased linearly (p = 0.001) with increasing levels of ADW. It is concluded that ADW containing aflatoxin B1 50 microg/kg DM can safely be incorporated in growing lamb feeding up to 353 g/kg diet without affecting growth and cellular immunity, however ADW may induce a transient alteration of hepatic enzymatic activities. Further aflatoxin content of the diet should be kept within permissible limits of respective country.

Socio-demographic characteristics of children infested with scabies in densely populated communities of residential madrashas (Islamic education institutes) in Dhaka, Bangladesh

BACKGROUND

Outbreaks of scabies in institutions and the socio-economic consequences have not been reported from overpopulated countries such as Bangladesh.

STUDY DESIGN

A community-based study among children from six residential Islamic education institutes (madrashas) in Dhaka. Multistage random sampling was used.

OBJECTIVES

To study the socio-economic profile, water-sanitation facilities, personal hygiene and living conditions of these children.

METHODOLOGY

Direct interviews were used to collect the data and clinical check up was performed in all children.

RESULTS

In total, 492 children received clinical check-ups; 92.5% were boys (mean age: 11.2+/-2.4 years). 63.4% of fathers and 98.5% of mothers were either illiterate or had only received primary education, 55.1% of fathers were in low-paid labouring jobs, and 99% of mothers were housewives. Of the 98% of children who had scabies, 71% had been re-infected (96% during the winter). Randomly assigned anti-scabies drugs revealed an average cure rate of 85.5%. Seventy-four percent of children were living in poorly ventilated buildings with overcrowded sleeping arrangements. They had poor personal hygiene: 21% shared towels; 8% shared undergarments; 30% shared bed linen; and 81% kept their used clothes on a communal line or shelf. Sanitation was also poor: 39% bathed infrequently, although 97% carried out mandatory ablution. Most children (61%) washed their clothes (including undergarments) two or three times a fortnight, 35% did so every 2-3 days, and 3.7% washed their clothes on alternative days. Disease severity and re-infection were associated with infrequent washing of clothes (P<0.001) and bed linen (P<0.001), overcrowded sleeping arrangements (P<0.001) and infrequent bathing (P<0.001) with soap (P<0.001). This was further related to household income (P<0.001 for both).

CONCLUSION

The study findings have potentially dangerous implications for public health. Immediate attention should be given to developing a sustainable long-term intervention programme to combat scabies hyperendemicity, and to save thousands of children from impending complications.

Genetic background influences UPR but not PLP processing in the rumpshaker model of PMD/SPG2

Mutations of the proteolipid protein gene (PLP1) cause Pelizaeus-Merzbacher disease (PMD) and Spastic paraplegia type 2 (SPG2). The rumpshaker mutation is associated with mild forms of PMD or SPG2 in man and the identical mutation occurs in mice, the phenotype depending on genetic background. The mild phenotype in C3H mice becomes a lethal disease when expressed on the C57BL/6 background. rumpshaker PLP is synthesised at a similar rate to wild type but is rapidly degraded by the proteasome. We show that the rates of synthesis, degradation and myelin incorporation of PLP/DM20 are similar in mutants on both backgrounds and therefore differences in PLP processing are unlikely to be the basis of the phenotypic variation. An unfolded protein response (UPR) is activated in rumpshaker. Whereas activation of CHOP correlates with phenotypic severity, we find no difference in the response of BiP and X-box protein1 (Xbp1) between the two strains.

Influence of ciliate protozoa on biochemical changes and hydrolytic enzyme profile in the rumen ecosystem

AIMS

To assess the effect of presence or absence of rumen protozoa on fermentation characteristics and enzyme profile in growing lambs.

METHODS AND RESULTS

Weaner lambs (G1, G2, G3, G4, G5 and G6 groups) were defaunated by oral administration of sodium laurel sulphate (at 8 g 100 kg(-1) body weight). The lambs of G4, G5 and G6 groups were refaunated. The roughage and concentrate ratio in the diet of G1 and G4, G2 and G5, and G3 and G6 were 50:50 (R1), 65:35 (R2) and 80:20 (R3), respectively. Daily dry matter intake was similar in defaunated and faunated lambs. However, digestibility of organic matter (OM), cellulose and gross energy were lower in defaunated lambs while crude protein (CP) digestibility was similar in both defaunated and faunated lambs. The rumen pH and NH3-N were lower (P < 0.01) while TVFA, total-N and TCA-ppt-N were higher (P < 0.01), in defaunated lambs. Ruminal activity of carboxymethyl cellulase was lower (P < 0.01) in defaunated lambs and amylase, xylanase, protease and urease were similar in faunated and defaunated lambs. Nutrient utilization, rumen metabolites and ciliate protozoal count were higher, whereas digestibility of fibre fractions was lower in high rather than low concentrate fed lambs. The rumen protozoa present before defaunation were B-type and the protozoa which re-established on refaunation were also B-type.

CONCLUSIONS

Absence of ciliate protozoa decreased nutrient digestibility and increased ruminal TVFA and total-N with lower NH3-N concentration, indicating better energy and protein utilization in defaunated lambs.

SIGNIFICANCE AND IMPACT OF THE STUDY

Defaunation improved energy and protein utilization in lambs.

Estimating HIV incidence rates from age prevalence data in epidemic situations

We present a method of estimating HIV incidence rates in epidemic situations from data on age-specific prevalence and changes in the overall prevalence over time. The method is applied to women attending antenatal clinics in Hlabisa, a rural district of KwaZulu/Natal, South Africa, where transmission of HIV is overwhelmingly through heterosexual contact. A model which gives age-specific prevalence rates in the presence of a progressing epidemic is fitted to prevalence data for 1998 using maximum likelihood methods and used to derive the age-specific incidence. Error estimates are obtained using a Monte Carlo procedure. Although the method is quite general some simplifying assumptions are made concerning the form of the risk function and sensitivity analyses are performed to explore the importance of these assumptions. The analysis shows that in 1998 the annual incidence of infection per susceptible woman increased from 5.4 per cent (3.3-8.5 per cent; here and elsewhere ranges give 95 per cent confidence limits) at age 15 years to 24.5 per cent (20.6-29.1 per cent) at age 22 years and declined to 1.3 per cent (0.5-2.9 per cent) at age 50 years; standardized to a uniform age distribution, the overall incidence per susceptible woman aged 15 to 59 was 11.4 per cent (10.0-13.1 per cent); per women in the population it was 8.4 per cent (7.3-9.5 per cent). Standardized to the age distribution of the female population the average incidence per woman was 9.6 per cent (8.4-11.0 per cent); standardized to the age distribution of women attending antenatal clinics, it was 11.3 per cent (9.8-13.3 per cent). The estimated incidence depends on the values used for the epidemic growth rate and the AIDS related mortality. To ensure that, for this population, errors in these two parameters change the age specific estimates of the annual incidence by less than the standard deviation of the estimates of the age specific incidence, the AIDS related mortality should be known to within +/-50 per cent and the epidemic growth rate to within +/-25 per cent, both of which conditions are met. In the absence of cohort studies to measure the incidence of HIV infection directly, useful estimates of the age-specific incidence can be obtained from cross-sectional, age-specific prevalence data and repeat cross-sectional data on the overall prevalence of HIV infection. Several assumptions were made because of the lack of data but sensitivity analyses show that they are unlikely to affect the overall estimates significantly. These estimates are important in assessing the magnitude of the public health problem, for designing vaccine trials and for evaluating the impact of interventions.

Syndrome packets and health worker training improve sexually transmitted disease case management in rural South Africa: randomized controlled trial

BACKGROUND

Sexually transmitted diseases (STD) are important co-factors in HIV transmission. We studied the impact of health worker training and STD syndrome packets (containing recommended drugs, condoms, partner notification cards and information leaflets) on the quality of STD case management in primary care clinics in rural South Africa.

METHODS

A randomized controlled trial of five matched pairs of clinics compared the intervention with routine syndromic management. Outcomes were measured by simulated patients using standardized scripts, and included the proportion given recommended drugs; correctly case managed (given recommended drugs plus condoms and partner cards); adequately counselled; reporting good staff attitude; and consulted in privacy.

RESULTS

At baseline, the quality of STD case management was similarly poor in both groups. Only 36 and 46% of simulated patients visiting intervention and control clinics, respectively, were given recommended drugs. After the intervention, intervention clinics provided better case management than controls: 88 versus 50% (P < 0.01) received recommended drugs; 83 versus 12% (P < 0.005) were correctly case managed; 68 versus 46% (P = 0.06) were adequately counselled; 84 versus 58% experienced good staff attitude (P = 0.07); and 92 versus 86% (P = 0.4) were consulted privately. A syndrome packet cost US$1.50; the incremental cost was US$6.80. The total intervention cost equalled 0.3% of annual district health expenditure.

INTERPRETATION

A simple and affordable health service intervention achieved substantial improvements in STD case management. Although this is a critical component of STD control and can reduce HIV transmission, community-level interventions to influence health-seeking behaviour are also needed.

Challenges in the conduct of vaginal microbicide effectiveness trials in the developing world

Conducting a phase III trial of a vaginal microbicide in a developing country poses several important and complex ethical challenges. As part of a process to bridge the gap between ethical theory and practice, we share our experiences in performing a phase III trial of Col 1492 (Advantage S) among female sex workers at four sites world-wide; Durban, Abidjan, Cotonou and Hat Yai. The ethical challenges included: (i) difficulties in obtaining informed consent. Participants were unable to grasp the concepts of a clinical trial for several weeks to months. In Cotonou, 30% of the women did not know the gel was tested for HIV prevention. Only 25% understood what a placebo was. In Durban, 70% of the women did not fully understand the study after 3 months; (ii) in sustaining the use of known HIV prevention strategies. Participants at the Durban site had difficulty in sustaining condom use due to financial and client preferences. Sex without condoms was worth more ($20) than sex with condoms ($10); (iii) in maintaining the confidentiality of the subject's HIV status. Novel approaches such as role plays and emphasis on other exclusion criteria were needed to maintain the confidentiality of women not included in the trial due to their HIV status; (iv) in providing care and support to the subjects who became infected with HIV during the trial. Women could only be offered routine sexually transmitted disease treatment and counselling. Anti-retrovirals were not offered. The successes and failures of the solutions attempted are described.

Improving quality of sexually transmitted disease case management in rural South Africa

OBJECTIVE

To measure quality of sexually transmitted disease (STD) syndromic case management and aspects of health-seeking behaviour at baseline in an intervention trial.

SETTING

Ten rural primary care clinics, Hlabisa district, South Africa.

DESIGN

Simulated patients (fieldworkers trained to present with STD syndromes) made a total of 44 clinic visits; 49 STD patients were interviewed when exiting clinics; facilities were assessed for availability of necessary equipment and drugs; 10 focus group discussions were held with staff; and STD syndrome surveillance was performed in all 10 clinics.

RESULTS

A total of 9% of simulated patients were correctly managed (given correct drugs, plus condoms and partner notification cards), recommended drug treatment was given in only 41% of visits, and appropriate counselling was given in 48% of visits. Among patients leaving the clinic, although 39% waited over an hour to be seen and only 37% were consulted in private, all reported staff attitudes as satisfactory or good. Only six clinics had syndromic management protocols available, three reported intermittent drug shortages, and seven lacked partner notification cards. Focus group discussions revealed good staff knowledge about STD, but showed lack of training in syndromic management and low morale. Surveillance data showed that while 75% of those presenting for care did so within 1 week of symptom onset, 27% had been treated for an STD in the preceding 3 months, and only 6% of those treated were contacts.

CONCLUSIONS

Quality of STD case management was poor despite good staff knowledge and availability of most essential resources. An intervention comprising staff training and STD syndrome packets has been designed to improve quality of case management.

Effects of first and second trimester vaginal bleeding on pregnancy outcome

The effects of vaginal bleeding during first and second trimester on pregnancy outcomes was assessed in a hospital-based population of 268 non-diabetic women. The group of non-bleeders comprised 173 females whereas, there were 71 females with first and 24 with second trimester bleeding. Fetal loss (abortion) occurred in 34% of first trimester and 25% of second trimester bleeders. Low birth weight and preterm delivery were significantly associated with second trimester haemorrhage. The results suggest that first and second trimester vaginal bleeding correlates with adverse infant outcomes.

Prevalence and severity of viral hepatitis in Pakistani pregnant women: a five year hospital based study

A hospital based observational study was carried out on pregnant women presenting with either acute hepatitis or fulminant hepatic failure (FHF), during the past years. Of 53 patients, 20 (38%) developed FHF.Non-A, Non-B was the commonest cause (62%) followed by hepatitis B in 17% and hepatitis A in 4% cases. Eight women expired (case fatality rate 15%) with a high maternal mortality (62%) caused by NANB hepatitis. Perinatal mortality was 30%. Poor prognostic factors identified were lack of antenatal care, severity of jaundice, history of somnolence, gastrointestinal bleeding and a high grade of encephalopathy.

An analysis of the cost of incomplete abortion to the public health sector in South Africa--1994

OBJECTIVE

To analyse the medical costs incurred in treating women for incomplete abortion. This study was performed in conjunction with a nationwide survey of women who presented to public hospitals with incomplete abortion in 1994.

DESIGN

Cost analysis with two modified Delphi panels used to develop models of resource use reflecting three severity categories of symptoms and three hospital treatment settings.

SETTING

Public hospitals in South Africa.

PARTICIPANTS

A panel of 15 senior level obstetrician/ gynaecologists and a second panel of 11 patient care managers representing district, regional and tertiary level hospitals in 7 provinces.

MAIN RESULTS

A conservative estimate of the total cost of treating women is R18.7 million +/- R3.5 million for 1994. An estimated R9.74 million +/- R1.3 million of this was spent treating women with 'unsafe' incomplete abortions.

CONCLUSIONS

The management of incomplete abortion requires significant public sector expenditure. The long-term indirect costs to women, their families and communities are discussed and treatment costs estimated so that unmet needs for medical care resulting from unsafe abortions can be addressed.

Fetal haemoglobin concentration and mean red cell volume are not related to the maternal values at 18-25 weeks' gestation

A cross-sectional study of 64 women and their fetuses undergoing cordocentesis at 18-25 weeks showed no significant correlation between maternal and fetal Hb or MCV and no relationship between these measurements and fetal abdominal circumference. We found no evidence for a nutritional or physiological association between maternal and fetal haematological status.

Anaemia in pregnancy--its cause in the underprivileged class of Karachi

A prospective study of the frequency and type of anaemia amongst poor urban parturients of Karachi was done. It was performed at 2 large teaching hospitals over the time span January to September, 1990. Out of 318 women studied, 104 (32.7%) were anaemic (Hb levels < 10gm/dl). The type of anaemia was assessed. Iron deficiency predominated and was seen amongst 63.5% of the anaemic population. There was an even distribution of other kinds of anaemia amongst the remainder of the population.

Preterm birth--its etiology and outcome

This is a retrospective case control study. Out of a total of 1238 births occurring over a period of 8 months at the Aga Khan University Medical Centre, Karachi, 9.4% were preterm. Factors found to be associated with preterm labour were age > 35, height < 156 cm, anaemia or urinary tract infection in pregnancy, abruptio placentae, polyhydramnios, preterm rupture of membranes, intrauterine growth retardation, fetal distress and intrauterine death. Previous bad obstetric history was also relevant. A preterm baby was found to be at higher risk of postnatal complications resulting in neonatal death or admission to the Neonatal Intensive Care Unit (NICU) than a full term baby.

Macrosomia: maternal and fetal outcome

This retrospective case--control study analyses the prevalence and outcome of macrosomia in a part of the underdeveloped world. Out of 6,093 deliveries at a large tertiary care centre, 234 (3.8%) were macrosomic. Maternal risk factors associated with the condition included age over 35, obesity, grand multiparity, postmaturity and impaired glucose tolerance. Operative deliveries were more common as was shoulder dystocia, birth trauma, fetal distress, the need for neonatal intensive care and perinatal loss.

A choice between glycogen and delta-crystallin accumulation is made in glial cells and not influenced by overlying neurons

Chick-embryo neuroretinal cells convert extensively into lens under low-glucose conditions, but this transdifferentiation process is blocked by high-glucose media. We have previously observed an inverse relationship between the levels of glycogen (a marker of normal retinoglial differentiation) and of delta-crystallin (a lens marker) in such cultures. However, most of the glycogen accumulated under high-glucose conditions is apparently localized in those glial (G) cells underlying clusters of neurons (N cells). We here show that glial-enriched cultures (largely depleted of N cells) both accumulate glycogen and fail to transdifferentiate in high-glucose media. Moreover, glycogen localization in groups of glial cells is unaffected by the absence of N cells. Thus the choice between normal and foreign differentiation pathways is made autonomously within the retinoglial-cell population and is not influenced significantly by the presence or absence of N cells.

Platelets and leucocyte counts in pregnancy

A study involving the obstetric clinic population of 3 major teaching hospitals of Karachi has been conducted to define changes in leucocyte and platelet counts as pregnancy progresses. 573 "normal" pregnant women--183 in the first trimester, 195 in the second trimester and 194 in the third trimester were included in this analysis. We have found leucocytosis to be a feature of normal pregnancy; the change is subsequent to a progressive increase in granulocytes. Platelet counts were found to decrease slightly as pregnancy progresses.

Stimulatory effects of retinal extract and fibroblast growth factor on lentoidogenesis in cultures of chick embryo neuroretinal cells

A crude extract prepared from embryonic chick retina stimulates growth and particularly transdifferentiation into lens when added as a supplement to neuroretinal (NR) cultures in vitro. This effect is especially marked when using a medium (H) containing 5% horse serum, where growth factors are likely to be limiting. The level of delta-crystallin (lens marker) production in such cultures increases with the concentration of extract. Using extracts from earlier and later stages of retinal development, there is an age-dependent decline in the extent to which transdifferentiation is stimulated. However, such extracts have little effect on the activity of CAT, a neuronal marker enzyme. These effects are most probably mediated by growth factors present in the retinal extract acting upon Müller glial cells or their precursors in the NR cultures. In support of this suggestion, we show that purified fibroblast growth factor (but not epidermal growth factor) exerts similar effects on both culture growth and delta-crystallin accumulation.

Glucose metabolism in transdifferentiating and glucose-blocked cultures of chick embryo neuroretinal cells: an inverse relationship between glycogen and delta-crystallin accumulation

Chick embryo neuroretinal (NR) cells transdifferentiate extensively into lens when cultured for several weeks in low-glucose (FH) medium, but fail to do so when high levels of supplementary glucose (FHG) are present. We show here that most aspects of glucose metabolism are promoted in high-glucose cultures, including lactate dehydrogenase (LDH) and glucose-6-phosphate dehydrogenase (G-6-PDH) activities, 2-deoxyglucose uptake, pentose shunt activity and lactate production. Continuous supplementation of high-glucose cultures with low levels of ouabain (FHGO) significantly lowers 2-deoxyglucose uptake, from FHG levels down towards FH levels, especially during the early stages of NR culture. Much later, extensive transdifferentiation into lentoids (with concomitant delta-crystallin accumulation) occurs in these FHGO cultures, which thus resemble FH rather than FHG controls. Another parameter strongly affected by ambient glucose levels is the accumulation of glycogen. Both glycogen itself and glycogen synthetase activity increase steadily in FHG cultures, but decrease slightly under FH conditions. Glycogen accumulation in FHG cultures is largely confined to glial-like cells, particularly those underlying clusters of neurones. Other studies have shown that glial differentiation in vitro is promoted by histotypic interactions with retinal neurones. Thus high glucose may act in concert with neuronal influences to stimulate or stabilize the normal differentiation of retinal glial cells, whose characteristic features in vivo include glycogen synthesis and storage. Furthermore, we show that supplementation of high-glucose cultures with forskolin or dibutyryl cyclic AMP (both of which promote glycogenolysis) results in a slower rate of glycogen accumulation and in enhanced transdifferentiation into lens. In both respects, the forskolin- and dibutyryl cAMP-supplemented FHG cultures are intermediate between FH and FHG controls. Thus the enhancement of normal glial differentiation in NR cultures by high glucose may inhibit or preclude subsequent transdifferentiation into lens.