Observational study of the medical management of patients with peripheral artery disease.

BACKGROUND: Previous research has suggested that patients with peripheral artery disease (PAD) are not offered adequate risk factor modification, despite their high cardiovascular risk. The aim of this study was to assess the cardiovascular profiles of patients with PAD and quantify the survival benefits of target-based risk factor modification. METHODS: The Vascular and Endovascular Research Network (VERN) prospectively collected cardiovascular profiles of patients with PAD from ten UK vascular centres (April to June 2018) to assess practice against UK and European goal-directed best medical therapy guidelines. Risk and benefits of risk factor control were estimated using the SMART-REACH model, a validated cardiovascular prediction tool for patients with PAD. RESULTS: Some 440 patients (mean(s.d.) age 70(11) years, 24·8 per cent women) were included in the study. Mean(s.d.) cholesterol (4·3(1·2) mmol/l) and LDL-cholesterol (2·7(1·1) mmol/l) levels were above recommended targets; 319 patients (72·5 per cent) were hypertensive and 343 (78·0 per cent) were active smokers. Only 11·1 per cent of patients were prescribed high-dose statin therapy and 39·1 per cent an antithrombotic agent. The median calculated risk of a major cardiovascular event over 10 years was 53 (i.q.r. 44-62) per cent. Controlling all modifiable cardiovascular risk factors based on UK and European guidance targets (LDL-cholesterol less than 2 mmol/l, systolic BP under 140 mmHg, smoking cessation, antiplatelet therapy) would lead to an absolute risk reduction of the median 10-year cardiovascular risk by 29 (20-38) per cent with 6·3 (4·0-9·3) cardiovascular disease-free years gained. CONCLUSION: The medical management of patients with PAD in this secondary care cohort was suboptimal. Controlling modifiable risk factors to guideline-based targets would confer significant patient benefit.

Peripheral T-cell lymphoma mimicking 5-aminosalicylate hypersensitivity in ulcerative colitis.

5-aminosalicylates (5-ASA) remain an important strategy in the induction and maintenance of remission of inflammatory bowel diseases especially in ulcerative colitis. The prototypical drug of this class, sulfasalazine is generally well tolerated with severe hypersensitivity reactions and hepatotoxicity also described within the literature. When approaching a patient with an adverse reaction to 5-ASA, it can be difficult to differentiate clinically between a sulfa allergy versus a 5-ASA allergy versus a malignancy. We report on a case with initial signs and symptoms suggestive of a sulfa/5-ASA allergy that was subsequently found to be malignant in nature.

Quantitative assessment of brain microvascular and tissue oxygenation during cardiac arrest and resuscitation in pigs.

Cardiac arrest is associated with a very high rate of mortality, in part due to inadequate tissue perfusion during attempts at resuscitation. Parameters such as mean arterial pressure and end-tidal carbon dioxide may not accurately reflect adequacy of tissue perfusion during cardiac resuscitation. We hypothesised that quantitative measurements of tissue oxygen tension would more accurately reflect adequacy of tissue perfusion during experimental cardiac arrest. Using oxygen-dependent quenching of phosphorescence, we made measurements of oxygen in the microcirculation and in the interstitial space of the brain and muscle in a porcine model of ventricular fibrillation and cardiopulmonary resuscitation. Measurements were performed at baseline, during untreated ventricular fibrillation, during resuscitation and after return of spontaneous circulation. After achieving stable baseline brain tissue oxygen tension, as measured using an Oxyphor G4-based phosphorescent microsensor, ventricular fibrillation resulted in an immediate reduction in all measured parameters. During cardiopulmonary resuscitation, brain oxygen tension remained unchanged. After the return of spontaneous circulation, all measured parameters including brain oxygen tension recovered to baseline levels. Muscle tissue oxygen tension followed a similar trend as the brain, but with slower response times. We conclude that measurements of brain tissue oxygen tension, which more accurately reflect adequacy of tissue perfusion during cardiac arrest and resuscitation, may contribute to the development of new strategies to optimise perfusion during cardiac resuscitation and improve patient outcomes after cardiac arrest.

Anemia increases the risk of renal cortical and medullary hypoxia during cardiopulmonary bypass.

INTRODUCTION: Anemia is an independent predictor of acute kidney injury (AKI) following cardiopulmonary bypass (CPB), possibly due to inadequate renal oxygen delivery. The objective of this study was to investigate the effects of CPB and anemia on tissue oxygen tension (pO2) and blood flow in the renal cortex and medulla. METHODS: Rats (n=6/group) underwent 1 hr of normothermic cardiopulmonary bypass (CPB), with target hemoglobin concentrations (Hb) of 10 g/dL (CPB) or 6.5 g/dL (anemia-CPB). Renal blood flow (RBF) and tissue PO2 were measured before, during and after 1 hr of CPB. To confirm the observed differences in renal cortical and medullary PO2, HIF-1α (ODD) luciferase mice were exposed to 8% O2 (hypoxia) and HIF-1α dependent luminescence was measured in the renal cortex and medulla (n=5). RESULTS: Renal tissue PO2 values decreased initially and returned towards baseline, however, values at the end of CPB. Anemia-CPB resulted in a significant increase in both renal cortical and medullary blood flow, PO2 remained significantly reduced throughout anemia-CPB. Renal medullary HIF-1α-dependent luminescence confirmed a greater degree of hypoxia in the renal medulla. DISCUSSION: During CPB, renal O2 delivery was transiently jeopardized, but recovered after 1 hr. Anemia-CPB resulted in a dramatic and sustained reduction in renal cortical and medullary PO2, which suggests an increased risk of renal hypoxic injury with anemia. CONCLUSION: The clear difference in the degree of hypoxia in the renal cortex and medulla may be useful in understanding the progress of medullary hypoxia during CPB with anemia and the potential development of AKI. Further studies should aim at identifying early markers of medullary hypoxia and potential agents that may decrease the work and O2 consumption in the renal medulla to reduce the risk of hypoxic damage during CPB and anemia.

HIV infection and contraceptive need among female Ethiopian voluntary HIV counseling and testing clients.

Despite political endorsement of voluntary HIV counseling and testing (VCT), and family planning integration in Ethiopia, little is known about the reproductive health needs of VCT clients. We estimated contraceptive prevalence and need among 646 Ethiopian female VCT clients. We compared socio-demographic characteristics of contracepting VCT clients to those with unmet need and examined how these characteristics are associated with having unmet contraceptive need and being HIV-positive using multinomial logistic regression. We also assessed the quality of VCT services from clients' reports of reproductive health topics discussed in VCT sessions. Nearly 34% of female VCT clients have unmet contraceptive need. Three socio-demographic characteristics are consistently associated with both risk for unintended pregnancy and HIV: older age, marriage, and lower education. In the multivariate analysis, older age, marriage, and belonging to a minority ethnic group are significantly associated with being both HIV-positive and having unmet contraceptive need. Conversely, higher education, larger families, and frequent sexual activity are associated with reduced likelihood of experiencing these two adverse health outcomes. VCT clients report infrequent reproductive health counseling, although HIV-positive women are more likely than HIV-negative women to have discussions about contraception with VCT counselors. At the time of this study, family planning was not offered as part of VCT programs, although VCT clients demonstrate considerable need for contraceptive services.

The role of delayed childbearing in the prevention of obstetric fistulas.

OBJECTIVE: To examine the role of delayed childbearing in the prevention of obstetric fistulas (OFs). METHODS: Data on 4798 deliveries in Niger (1995-1998), 3552 in Nigeria (1996-1999), and 6789 in Tanzania (1991-1996) were analyzed with logistic regression models. RESULTS: Young maternal age and primiparous status were identified as correlates of prolonged/obstructed labor. The annual incidence of OFs in Nigeria was found to be 2.11 per 1000 births, with 9817 cases developing each year, 28% in women and girls younger than 20 years. The predicted proportion of women experiencing prolonged/obstructed labor would be reduced by 11.2% in Niger, 11.4% in Nigeria, and 13.1% in Tanzania if the risks associated with young maternal age at first delivery and primiparity were eliminated. CONCLUSIONS: Community programs to educate young, newly married women about delaying childbearing until they reach physical maturity should be implemented in countries with a high incidence of OFs.

MRI grading versus histology: predicting survival of World Health Organization grade II-IV astrocytomas.

BACKGROUND AND PURPOSE: Histologic grading of intracranial astrocytomas is affected by sampling error and substantial inter- and intraobserver variability. We proposed that incorporating MR imaging into grading will predict patient survival more accurately than histopathology alone. MATERIALS AND METHODS: Patients with a new diagnosis of World Health Organization grades II-IV astrocytoma or mixed oligoastrocytoma diagnosed between September 2007 and December 2010 were identified. Two hundred forty-five patients met the inclusion criteria. Preoperative MRIs were independently reviewed by 2 readers blinded to the histologic grade, and an MR imaging grade was given. The MR imaging and histopathologic grades were compared with patient survival. RESULTS: Patients with grade II or III astrocytomas on histology but evidence of necrosis on MR imaging (consistent with a grade IV tumor) had significantly worse survival than patients with the same histology but no evidence of necrosis on MR imaging (P = .002 for grade II histology and P = .029 for grade III). Their survival was not significantly different from that in patients with grade IV tumors on histology (P = .164 and P = .385, respectively); this outcome suggests that all or most are likely to have truly been grade IV tumors. MR imaging evidence of necrosis was less frequent in grade II and III oligoastrocytomas, preventing adequate subgroup analysis. CONCLUSIONS: MR imaging can improve grading of intracranial astrocytomas by identifying patients suspected of being undergraded by histology, with high interobserver agreement. This finding has the potential to optimize patient management, for example, by encouraging more aggressive treatment earlier in the patient's course.

Maternal and sociodemographic correlates of child morbidity in Bas Zaire: the effects of maternal reporting.

Cross-sectional survey data, collected in Bas Zaire from the mothers of 1200 urban and 1670 rural children born in the last 5 years, are used to assess variations in diarrheal, malarial, helminthic, and other child morbidities by selected household, maternal and child factors. In a multivariate analysis, we focus on maternal age and birth order as determinants of recent illnesses to observe any parallels in their effects on child mortality. These relationships are found after adjusting for bias from differential maternal perceptions of illnesses.

Rumor, misinformation and oral contraceptive use in Egypt.

Rumor and misinformation about oral contraceptives continue to prevail in much of Egypt. This study tests the hypothesis that rumor involvement can have a negative and independent impact on pill usage by focusing on a common misbelief that the pill causes 'weakness'. The data comes from a 1981-1982 national self-weighted sample survey of 3283 currently married men and women dealing with family planning and mass media behaviors. The analyses confirm that rumor involvement decreases the probability of current or future pill use by previous users and by those who have never used it. Correct knowledge about the pill is shown to enhance pill usage as do other determinants such as social support for birth control and the desire for no more children. The importance of providing strong contraceptive education programs giving deeper consideration to contraceptive and related health beliefs in delivering fertility regulation services is highlighted.

The meaning of RTI in Vietnam--a qualitative study of illness representation: collaboration or self-regulation?

In collaboration with the National Committee for Population and Family Planning, a study was conducted in a rural and urban commune of northern Vietnam to provide community-level information about women's reproductive health and behaviors. Ethnographic and structured interviews were conducted with 32 women. A psychosocial model of health behavior, the Dual Process Model, was applied to provide a theoretical framework for understanding women's interpretations of, and strategies for, coping with symptoms of reproductive tract infections (RTIs). Women were found to interpret and manage RTI symptoms collaboratively with other women. Therefore, women's approach to care seeking was influenced heavily by their peer network and not driven by their method of family planning.

Declining world fertility: trends, causes, implications.

This Bulletin examines the evidence that the world's fertility has declined in recent years, the factors that appear to have accounted for the decline, and the implications for fertility and population growth rates to the end of the century. On the basis of a compilation of estimates available for all nations of the world, the authors derive estimates which indicate that the world's total fertility rate dropped from 4.6 to 4.1 births per woman between 1968 and 1975, thanks largely to an earlier and more rapid and universal decline in the fertility of less developed countries (LDCs) than had been anticipated. Statistical analysis of available data suggests that the socioeconomic progress made by LDCs in this period was not great enough to account for more than a proportion of the fertility decline and that organized family planning programs were a major contributing factor. The authors' projections, which are compared to similar projections from the World Bank, the United Nations, and the U.S. Bureau of the Census, indicate that, by the year 2000, less than 1/5 of the world's population will be in the "red danger" circle of explosive population growth (2.1% or more annually); most LDCs will be in a phase of fertility decline; and many of them -- along with most now developed countries -- will be at or near replacement level of fertility. The authors warn that "our optimistic prediction is premised upon a big IF -- if (organized) family planning (in LDCs) continues. It remains imperative that all of the developed nations of the world continue their contribution to this program undiminished."

The international family planning movement.

PIP: Over the past 3 decades, the number of women using family planning has increased 6-fold to over 400 million married women of childbearing age. The evolution of behavior and attitudes toward using birth control among third world couples reflects the goals and hard work of an international network of individuals, governments and organizations. This article follows the progression of this movement, from early opposition in developed as well as developing countries, to the present day, when birth control is practiced by a slight majority of the world's women of childbearing age. Among world regions, contraceptive use ranges from about 17% in Africa to 75% in Asia. In some African countries, however, family planning is still a foreign concept, and fewer than 5% of women use any birth control. International organizations played a crucial role in spread of family planning by providing training for developing country professionals, funding actual family planning programs and helping to evaluate programs. But the success of a country's family planning program also was dependent upon a national commitment, and often on a strong socioeconomic setting. The private sector has had a limited role except in some countries, notably in Latin America, but its involvement is likely to expand in the future. Also, as financial support from the US and international organizations wanes, national governments will cover a larger share of the cost. The worldwide increase in the practice of family planning has led to fertility declines in many third world countries, slowing rapid population growth rates. For individuals, family planning has been a liberating influence, allowing them to participate more fully in the shift from traditional to modern society.^ieng

Tetanus immunization and prenatal care in developing countries.

OBJECTIVE: We sought to estimate the proportion of women immunized against tetanus while attending prenatal care in the developing countries. METHOD: We computed the ratio of the percentage of births to women immunized against tetanus to the percentage of births to women with prenatal care (TP ratio). A TP ratio is lower than 100% if not every woman attending prenatal care is immunized. We used 1986-1992 Demographic and Health Surveys data from 38 countries. RESULTS: The mean TP ratios were 86% in Africa (n = 23), 79% in Asia (n = 6) and 60% in Latin American and the Caribbean (n = 9). The TP ratio was lower than 75% in 15 countries. Of these, four had a TP ratio lower than 50%. CONCLUSION: In many countries the number of pregnant women immunized against tetanus is lower than the number of women attending prenatal care, suggesting that prenatal services are missing opportunities to immunize attending women.

The relationship between prenatal care and subsequent modern contraceptive use in Bolivia, Egypt and Thailand.

Determinants of modern contraceptive use are usually examined in isolation of the effect of exposure to other aspects of health care systems. Maternal interaction with organised health service provision during post-conception and postpartum stages of reproduction can provide an opportunity to transfer contraceptive service information and counselling. We found that living in a community in which women have widespread health service contact is related to both prenatal care use and subsequent modern contraceptive use. After controlling for effects of living in high health service contact areas and various demographic and background factors, our results suggest that prior use of prenatal care has a strong influence on subsequent use of modern contraception in Bolivia, Egypt and Thailand.

Preoperative evaluation of oral tongue squamous cell carcinoma with intraoral ultrasound and magnetic resonance imaging-comparison with histopathological tumour thickness and accuracy in guiding patient management.

The aim of this study was to investigate the correlation between tumour thickness (TT) on intraoral ultrasound (US) and magnetic resonance imaging (MRI) with the histologically determined TT of tongue cancers. Secondary objectives included evaluation of potential confounders that affect this association and the predictive value for simultaneous neck dissection. Eighty-eight consecutive patients referred to the study institution between January 2007 and August 2012 with the presumptive diagnosis of invasive squamous cell carcinoma (SCC) of the tongue were analyzed. Seventy-nine patients had preoperative US and 81 had MRI. Correlation between image-determined TT and histological TT was assessed by Bland-Altman plot and Pearson's correlation coefficient. Potential confounders were assessed by subgroup analysis. Preoperative TT as determined by US demonstrated high correlation and MRI moderate correlation with histological TT. With subgroup analysis, negative associations were biopsy prior to imaging and resection diagnosis other than invasive SCC. Our experience suggests that US could be considered the initial modality of choice for preoperative assessment of TT.

Sexually Transmitted Infection (STI) screening, case and contact treatment, and condom promotion resulting in STI reduction two years later in rural Malawi.

As part of a longitudinal cohort study in rural Malawi in 2000, 469 men and 758 women were asked to respond to a series of surveys, were tested for gonorrhea and chlamydia, and received their results and treatment, if applicable, for themselves and up to 2 partners if positive for either sexually transmitted infection (STI). Two years later, in 2002, 328 men and 525 women were again asked to respond to survey questions, tested again for gonorrhea and chlamydia, and were also tested for HIV--of these, 247 men and 453 women had also given urine samples in 2000. In 2000, the gonorrhea and chlamydia prevalence was 6.2% and 5.8% among men, and 3.6% and 4.9% among women. Two years later, prevalence of gonorrhea and chlamydia was 0.7% and 1.4% among men, and 1.3% and 1.1% among women. Although we did not test for HIV in the first round, the HIV prevalence in 2002 was 19.2%. The implications of the findings are discussed in the context of interventions for STI prevention and to reduce HIV transmission in sub-Saharan Africa.

Are wider surgical margins needed for early oral tongue cancer?

BACKGROUND: Traditionally, a 1-cm surgical resection margin is used for early oral tongue tumours. METHODS: All tumour stage one (n = 65) and stage two (n = 13) oral tongue cancers treated between January 1999 and January 2009 were followed for a median of 38 months (minimum 12 months). The sites of close and involved margins were histologically reviewed. RESULTS: Involved and close margins occurred in 14 and 55 per cent of cases, respectively. The number of involved vs clear or close margins was equivalent in tumour stage one (90 vs 82 per cent), node-negative (100 vs 84 per cent) and perineural or lymphovascular invasion (20 vs 21 per cent) cases. Close or involved margins were similarly likely to be posterior (59 per cent) as anterior (41 per cent, p = 0.22), lateral (57 per cent) as medial (43 per cent, p = 0.34), and mucosal (59 per cent) as deep (41 per cent, p = 0.22). Local recurrence occurred in 28 per cent of cases at a median of 12 months, and was more likely in cases with involved (50 per cent) than clear or close margins (25 per cent, p = 0.10). Disease-free survival was worse in involved margins cases (p = 0.002). CONCLUSION: Involved margins are common in early tongue tumours, and are associated with increased local recurrence and worse survival. Close or involved margins occur in all directions and all tumour types. A wider margin may be justified.

Outcomes of patients with adenoid cystic carcinoma of the minor salivary glands.

Adenoid cystic carcinoma is a tumour of glandular cells responsible for 10% of salivary gland neoplasms. It has a high rate of perineural spread but limited involvement of regional lymphatics even in late stage disease. Early survival is typically good (60-90%) although long term survival is poor with spread to distant sites in 40-60% of cases. The authors performed a retrospective review of clinical and pathological records for 24 patients managed by their institution over a 22-year period. The overall 5, 10 and 20-year survival rates in this study were 92%, 72% and 54%, respectively. Perineural invasion was seen in 63% and close or positive margins seen in 64% of all primary resection specimens although survival was not associated with any clinical factor other than the initial size of lesion. Most patients presented complaining of a lump, whilst a burning neuralgia-type pain was the second most common symptom. The study confirms the conclusion of previous studies that tumour size at diagnosis is the most important predictor of outcome.

Metastatic prostate adenocarcinoma invading an atypical meningioma.

Although prostate adenocarcinoma is the most commonly diagnosed cancer in men, intracranial metastases are rare. We describe a 72-year-old patient with known metastatic prostate cancer, presenting with a dural-based parafalcine lesion on radiological imaging, following a seizure. Total macroscopic excision of the lesion was achieved at surgery, with histopathology confirming prostate adenocarcinoma embedded in an atypical (World Health Organization Grade II) meningioma, fulfilling all the criteria for true tumour-to-tumour metastasis. To our knowledge, this is the first report of prostate cancer metastasising to an atypical meningioma.

Experiences with fistula repair surgery among women and families in Malawi.

Fistula treatment through surgery is reported to be successful in 80-90% of cases. Success in fistula repair has been defined by medical professionals in terms of clinical outcomes; beyond these definitions, it is important to understand how women perceive a positive clinical outcome and how it affects her family and home environment. This research was conducted in the Mangochi District of Malawi to answer these questions through interviews with women living with fistula and after surgical repair, as well as their partners and families. Over 104 interviews were conducted in June and October 2007. While eventually experiencing clinically successful surgical outcomes, women reported difficulty in seeking and receiving healthcare. Bureaucratic challenges were complicated by community misperceptions about the condition and fear of the healthcare system. Perspectives of women's families suggest that burdens and social disabilities caused by fistula extended beyond the individual to affect these family members. When women experienced surgical treatment, positive outcomes spread to her family and community. Positive experiences with the healthcare system turned women into advocates for healthcare in their communities. These findings illustrate that issues of obstetric fistula are not limited to individual women, but can dramatically affect their families, partners and communities.