Did point-of-use drinking water strategies for children change in the Dominican Republic during a cholera epidemic?

OBJECTIVE: Point-of-use (POU) strategies to improve drinking water, particularly chlorination, are promoted within cholera epidemics when centrally delivered safe drinking water is lacking. Most studies examining POU practices during cholera epidemics have relied on single cross-sectional studies which are limited for assessing behavioural changes. This study examined POU practices in a community over time during a cholera outbreak. STUDY DESIGN: Secondary data analysis of existing dataset. METHODS: During attendance at well-baby clinics serving a low-income peri-urban community in the Dominican Republic, mothers had been routinely asked, using a structured questionnaire, about POU strategies used for drinking water for their children. Frequency distribution of reported practices was determined over a 21 month period during the cholera outbreak on the island of Hispaniola. RESULTS: An estimated 27.8% of children were reported to have had some exposure to untreated tap water. Unsustained reductions in exposure to untreated tap water were noted early in the epidemic. POU chlorination was infrequent and showed no significant or sustained increases over the study time period. CONCLUSION: High reliance on bottled water, consistent with national household patterns prior to the cholera outbreak, may have reduced the perceived need for POU chlorination. Examination of the safety of relying on bottled water during cholera outbreaks is needed. Additionally, further inquiries are needed to understand variation in POU practices both during and beyond cholera outbreaks.

A review of pre-admission advanced airway management in combat casualties, Helmand Province 2013.

OBJECTIVES: Airway compromise is the third leading cause of potentially preventable combat death. Pre-hospital airway management has lower success rates than in hospital. This study reviewed advanced airway management focusing on cricothyroidotomies and supraglottic airway devices in combat casualties prior to admission to a Role 3 Hospital in Afghanistan. METHODS: This was a retrospective review of all casualties who required advanced airway management prior to arrival at the Role 3 Hospital, Bastion, Helmand Province over a 30-week period identified by the US Joint Theatre Trauma Registry. The notes and relevant X-rays were analysed. The opinions of US and UK clinical Subject Matter Experts (SME) were then sought. RESULTS: Fifty-seven advanced airway interventions were identified. 45 casualties had attempted intubations, 37 (82%) were successful and of those who had failed intubations, one had a King LT Airway (supraglottic device) and seven had a rescue cricothyroidotomy. The other initial advanced airway interventions were five attempted King LT airways and seven attempted cricothyroidotomies. In total, 14 cricothyroidotomies were performed; in this group, there were nine complications/significant events. CONCLUSIONS: The SMEs suggested that dedicated surgical airway kits should be used and students in training should be taught to secure the cricothyroidotomy tube as well as how to insert it. This review re-emphasises the need to 'ensure the right person, with the right equipment and the right training, is present at the right time if we are to improve the survival of patients with airway compromise on the battlefield'. The audit reference number is RCDM/Res/Audit/1036/12/0368.

Long term follow up of BRCA1 and BRCA2 mutation carriers with unsuspected neoplasia identified at risk reducing salpingo-oophorectomy.

OBJECTIVES: The reported incidence of neoplasia identified at the time of risk-reducing salpingo-oophorectomy (RRSO) in germline BRCA1/2 mutation carriers ranges from 4 to 12% but long-term outcomes have not been described. We evaluated recurrence and survival outcomes of mutation carriers with neoplastic lesions identified at RRSO. METHODS: We identified BRCA1/2 mutation carriers with neoplasia at RRSO at three institutions. Data was collected on clinical variables, adjuvant treatment and follow-up. RESULTS: We identified 32 mutation carriers with invasive carcinomas (n=15) or high-grade intraepithelial neoplasia (n=17) that were not suspected prior to surgery. 26 occurred in BRCA1 and 6 in BRCA2 mutation carriers. Median and mean age for carcinomas were 50 years and 49.3 respectively, significantly younger than for intraepithelial neoplasm, median 53 years, and mean 55 years (p=0.04). For the 15 invasive carcinomas, median follow up was 88 months (range 45-172 months), 7 recurred (47%), median time to recurrence was 32.5 months and 3 have died of disease; 1 additional patient died of breast cancer. Overall survival was 73%, disease specific overall survival was 80% and disease free survival was 66%. For the 17 high-grade intraepithelial neoplasms, median follow up was 80 months (range 40-150), 4 were treated with chemotherapy. One recurred at 43 months and is currently not on therapy with a normal CA125, 16 months later. All patients with noninvasive neoplasia are alive. CONCLUSIONS: BRCA1 and BRCA2 mutation carriers with unsuspected invasive carcinoma at RRSO have a relatively high rate of recurrence despite predominantly early stage, small volume disease. High-grade intraepithelial neoplasms rarely recur as carcinoma and may not require adjuvant chemotherapy.

Implementation of a personalized workplace smoking cessation programme.

BACKGROUND: Providing smoking cessation programmes through workplaces is an effective method of assisting employees to quit smoking; however, few employers provide such services, and achieving long-term success remains challenging. AIMS: To evaluate the effectiveness of a workplace-based tailored smoking cessation programme that combined telephone-based counselling with group behaviour therapy sessions in helping employees to quit. METHODS: A smoking cessation programme was offered to employees of a large corporation that is respons ible for the passenger rail network in New South Wales (NSW), Australia. Two hundred and thirty participants enrolled in the programme, which offered telephone-based coaching and group sessions designed around cognitive behavioural therapy principles. One hundred and eight participants (47%) completed the 6 month follow-up assessment. RESULTS: Of the estimated 2850 smokers in the organization, 8% (230) registered for the smoking cessation programme, with 77% (176) participating in telephone-based coaching and/or group sessions. Intention-to-treat analysis indicated 22% of participants achieved 7 day point prevalence abstinence and 10% achieved 3 month prolonged abstinence at the 6 month follow-up. Over 75% of those still smoking at follow-up reported intentions to quit in the next 6 months. Psychological distress was also significantly lower at 6 month follow-up. Participants reported high levels of satisfaction with the programme. CONCLUSIONS: The smoking cessation programme successfully assisted employees to quit smoking. Unique aspects of the programme such as continuity of care were valued by participants and may have contributed to the programme's success.

Predictors of contralateral breast cancer in BRCA1 and BRCA2 mutation carriers.

PURPOSE: The objective of this study was to estimate the risk of contralateral breast cancer in BRCA1 and BRCA2 carriers; and measure the extent to which host, family history, and cancer treatment-related factors modify the risk. PATIENTS AND METHODS: Patients were 810 women, with stage I or II breast cancer, for whom a BRCA1 or BRCA2 mutation had been identified in the family. Patients were followed from the initial diagnosis of cancer until contralateral mastectomy, contralateral breast cancer, death, or last follow-up. RESULTS: Overall, 149 subjects (18.4%) developed a contralateral breast cancer. The 15-year actuarial risk of contralateral breast cancer was 36.1% for women with a BRCA1 mutation and was 28.5% for women with a BRCA2 mutation. Women younger than 50 years of age at the time of breast cancer diagnosis were significantly more likely to develop a contralateral breast cancer at 15 years, compared with those older than 50 years (37.6 vs 16.8%; P=0.003). Women aged <50 years with two or more first-degree relatives with early-onset breast cancer were at high risk of contralateral breast cancer, compared with women with fewer, or no first-degree relatives with breast cancer (50 vs 36%; P=0.005). The risk of contralateral breast cancer was reduced with oophorectomy (RR 0.47; 95% CI 0.30-0.76; P=0.002). CONCLUSION: The risk of contralateral breast cancer risk in BRCA mutation carriers declines with the age of diagnosis and increases with the number of first-degree relatives affected with breast cancer. Oophorectomy reduces the risk of contralateral breast cancer in young women with a BRCA mutation.

An evaluation of social skills in children with and without prenatal alcohol exposure.

BACKGROUND: The goal of this study was to examine social skills deficits among children with and without prenatal alcohol exposure (PAE) who were both referred to a respite programme. METHODS: Thirty-seven children with PAE and 23 non-exposed children (aged 3 to 8 years) were evaluated on the Social Skills Rating System (SSRS) by their caregivers and respite workers. RESULTS: As compared with the non-exposed children, those with PAE showed more deficits on caregiver ratings of responsibility, hyperactivity, internalizing problems and overall social skills, as well as respite worker ratings of hyperactivity. The social skills among the PAE group were not related to home placement variables. Among both groups, caregivers rated social skills lower than respite workers, and among the PAE group, girls tended to display more social skills deficits than boys. CONCLUSIONS: The SSRS is useful in identifying unique social skills deficits among children with PAE.

Blister beetle dermatitis caused by cantharidin in South Sudan in Op TRENTON: a case series.

Cantharidin-producing blister beetles are found worldwide. The pathognomonic feature of their toxin is a blistering dermatitis that presents an environmental health hazard. Cutaneous exposure to cantharidin can produce blistering dermatitis, most commonly seen on exposed skin, in the Bentiu region of South Sudan. This should be treated with appropriate cleaning, debridement and regular dressing changes to cope with extensive initial exudate. The best dressing combinations found were initial treatment with povidone-iodine and hydrocolloid, followed by hydrocolloid only. Hydrocolloid dressings were found to be the most effective at staying in place with South Sudan's high humidity. Prevention strategies should include covering exposed skin, wearing wide-brimmed hats, neck scarves and enclosed footwear, and avoidance of working under white light. Medical personnel should engage with the chain of command to include appropriate force protection education within the arrivals brief.

Participation in a parent education programme in the Dominican Republic: utilization and barriers.

There has been a limited assessment of the extent of participation in parent education programmes and the factors influencing attendance. This is particularly the case for low- and middle-income countries. Experiences with an eight-session education programme offered to caregivers of malnourished children in the Dominican Republic were examined. Overall, 57% of a total of 143 caregivers completed more than half of the programme. This value increased from 41% to 79% following a midstream change in service delivery, which entailed concentrating the programme into a shorter period of time and pairing it with a more intensive child nutrition component. Other hypothesized variables did not predict attendance. Key barriers to attendance identified in qualitative interviews included lack of money for transportation, lack of an acceptable babysitter for other children and competing demands on the caregivers' time. Efforts to eliminate caregiver identified barriers may improve participation levels.

'Jumping through hoops': parents' experiences with seeking respite care for children with special needs.

BACKGROUND: Respite care may act as a means to reduce stress and fatigue in people caring for a dependent who has a disability. Despite this, a variety of barriers may exist to obtaining such services. This study explored caregivers' experiences seeking respite care for their children with special needs within a province in Canada. METHODS: Caregivers were recruited from two agencies providing respite care for children with fetal alcohol spectrum disorders and other mental health and developmental difficulties. In total, 10 caregivers participated in in-depth individual interviews. A constructivist grounded theory approach was employed in the design and analysis of the data. RESULTS: Caregivers discussed their frustrations with the process of finding and obtaining respite care, a course of action described as 'jumping through hoops'. This construct was composed of subcategories emphasizing the complexity of 'navigating the system', the bidirectional process of 'meeting the requirements' and the challenges of 'getting help'. CONCLUSIONS: The collective experiences of these caregivers point to the need for more flexibility and co-ordination of respite care services for children with special needs.

Is methoxyflurane a suitable battlefield analgesic?

Anecdotal reports of mechanical failure of morphine autojets have triggered a review of possible alternatives. Methoxyflurane is one such alternative already widely used by the Australian and New Zealand Defence Forces. The potential benefits and likely significant drawbacks of methoxyflurane are reviewed with the aim of stimulating discussion.

Alcohol dehydrogenase of class I: kiwi liver enzyme, parallel evolution in separate vertebrate lines, and correlation with 12S rRNA patterns.

Alcohol dehydrogenase class I from kiwi liver has been purified, analyzed, and compared with that of other alcohol dehydrogenases. The results show that several avian and mammalian forms of the enzyme exhibit parallel evolutionary patterns in two independent lineages of a single protein, establishing a pattern in common. Furthermore, the data correlate the enzyme evolutionary pattern with that of 12S rRNA. Biologically, the patterns complement those on ratite and other avian relationships. Functionally, the enzyme has a low Km with ethanol and a branched-chain residue at position 141, like the mammalian enzymes but in contrast to the other characterized ratite enzyme (with Ala-141 and a higher Km). This pattern of natural variability suggests a frequent but not fully complete correlation between a large residue size at position 141 and tight ethanol binding.

Learning-dependent Changes in the Responses to Visual Stimuli of Neurons in a Recognition Memory System.

When young chicks are trained by exposing them to a conspicuous object they learn its characteristics. The learning process is known as imprinting. In the present study neuronal activity in a region crucial for imprinting was shown to be affected by training and by the object on which the chicks had been trained. The region is the intermediate and medial part of the left hyperstriatum ventrale (left IMHV). No such effects were found in a visual projection area, the left hyperstriatum accessorium. Domestic chicks were imprinted on either a rotating red box (n=7 chicks) or a rotating blue box (n=8). When the chicks were approximately 48 h old they were anaesthetized and multiple-unit activity was recorded in simultaneous, single penetrations through each of the two regions. Records were also made from eight dark-reared chicks. Whilst recording, the red or blue box, placed in front of the contralateral eye, was switched on to give a total of 20 rotations, the interval between each rotation being 10 s. The alternative stimulus was then presented 20 times. Unit activity in the 3 s before and after stimulus onset was compared and the data for each of the 20 presentations were combined. In the left IMHV 18 out of a total of 115 recording sites (16%) responded significantly to the stimuli; in the left hyperstriatum accessorium 39 out of 126 recording sites (26%) did so. Measures of unit activity at each recording site were combined for a given penetration to provide a 'mean penetration response'. The response to the red box differed from the response to the blue box in the left IMHV of dark-reared chicks. After training with the blue box the response to both boxes was similar to the response to the blue box in dark-reared birds. After training with the red box the response to both boxes was similar to the response to the red box in dark-reared birds. No significant effects were found in the left hyperstriatum accessorium. The two training boxes were virtually identical apart from the differences in colour and brightness. Training appeared to stabilize the response of the visually naive left IMHV to the training stimulus whilst changing its response to the alternative, but similar stimulus. That is, one consequence of training is that the two stimuli are placed in the same category, and this neural change may provide a basis for stimulus generalization. The underlying neural system is modelled and a mechanism that allows such stimuli to be discriminated is proposed.

Food antibodies in oral disease: a study of serum antibodies to food proteins in aphthous ulceration and other oral diseases.

We have investigated the incidence of antibodies to food antigens in patients with recurrent minor aphthous ulceration and in patients with other oral ulcerative diseases. The incidence of these antibodies was the same in both groups of patients and was significantly greater than the incidence in a control group of normal people. There was no evidence to support the hypothesis that aphthous ulceration is primarily due to hypersensitivity to food antigens. The factors which might contribute to the absorption of antigenic molecules from the mouth and to the increased immune response in patients with oral disease have been considered.

Prevalence, persistence, and correlates of depressive symptoms in a national sample of mothers of toddlers.

OBJECTIVES: To examine the prevalence, persistence, and correlates of depressive symptoms in mothers of toddlers in a nationally representative sample. METHOD: The self-report components of two linked databases were used for this study, the 1988 National Maternal and Infant Health Survey and the 1991 Longitudinal Followup. Depressive symptoms of 7,537 mothers were measured by the Center for Epidemiologic Studies-Depression Scale (CES-D) at both time points. Weighted bivariate and multivariate analyses were used to assess the stability of maternal depressive symptoms across two time points and maternal and child predictors of elevated depressive symptoms. RESULTS: Twenty-four percent of mothers at time 1 (mean child age 17 months) and 17% at time 2 (mean child age 35 months) had elevated depressive symptoms (CES-D score > or =16). Thirty-six percent of those with elevated scores at time 1 also had elevated scores at time 2. Not having breast-fed, a mistimed or unwanted pregnancy, and poor child health status were related to elevated depressive symptoms but not persistence. CONCLUSIONS: Elevated depressive symptoms are common in mothers of toddlers. Given the potential magnitude of need, a systematic clinical and public health approach may be required.

Transcranial enucleation for optic nerve tumor.

Tumors involving both the eye and the optic nerve present a special surgical problem. Conventional enucleation techniques neither permit the surgical exploration of the optic nerve nor assure the complete removal of tumor within the orbit, and they often involve transection through tumor-containing tissue. Transcranial enucleation permits the inspection of the tumor from the back of the globe to the chiasm and its en bloc removal.

Mechanisms of hyperventilation in head injury: case report and review.

We report the case of a head-injured patient with spontaneous hyperventilation who had recurrent episodes of relative hypoventilation associated with increases in intracranial pressure. Detailed ventilatory studies were performed during the 2nd week after injury. Our findings in this patient prompted us to review the possible mechanisms underlying the observed changes. We suggest that spontaneous hyperventilation in head injury is secondary to a decrease in cortical inhibitory influences on respiratory control mechanisms and that the transient episodes of relative hypoventilation observed in our patient may reflect modified ventilatory responses dependent on the altered state of consciousness. (Neurosurgery, 5: 701--707, 1979).

Malignant teratoma arising within a lipomeningocele. Case report.

The authors report the case of an 11-year-old, neurologically normal girl, followed since birth for lipomeningocele, who developed a malignant teratoma within the lymbosacral lesion and presented with metastases to the lungs and groin. This rare occurrence is discussed from an embryological and management viewpoint.

Radionuclide cisternographic evaluation and follow-up of posttraumatic subconjunctival CSF loculation. Case report.

The case of a patient with massive, posttraumatic, subconjunctival cerebrospinal fluid collections is described in which diagnosis and postoperative management was simplified by serial radionuclide cisternography.

Extradural spinal involvement by gout. Case report.

A case of extradural gouty tophus in the lumbar region in a teen-age girl is presented as an addition to the differential diagnosis of erosive lesions of the spinal canal.

Cortical vein thrombosis in Wegener's granulomatosis. Case report.

A patient with Wegener's granulomatosis is reported in whom a life-threatening cortical vein thrombosis was identified as the process causing acute neurological deterioration. The literature dealing with the neurological and neuropathological manifestations in Wegener's granulomatosis is reviewed.