British Association of Dermatologists National Clinical Audit on the Management of Hidradenitis Suppurativa in the UK.

BACKGROUND: The first UK guidelines for the management of hidradenitis suppurativa (HS) were published by the British Association of Dermatologists (BAD) in 2018. The guidelines contained a set of audit criteria. AIM: To evaluate current HS management against the audit standards in the BAD guidelines. METHODS: BAD members were invited to complete audit questionnaires between January and May 2020 for five consecutive patients with HS per department. RESULTS: In total, 88 centres participated, providing data for 406 patients. Disease staging using the Hurley system and disease severity using a validated tool during follow-ups was documented in 75% and 56% of cases, respectively, while quality of life and pain were documented in 49% and 50% of cases, respectively. Screening for cardiovascular disease risk factors was as follows: smoking 75%, body mass index 27% and others such as lipids and diabetes 57%. Screening for depression and anxiety was performed in 40% and 25% of cases, respectively. Support for smokers or obese patients was documented in 35% and 23% of cases. In total, 182 patients were on adalimumab, of whom 68% had documentation of baseline disease severity, and 76% were reported as having inadequate response or contraindications to systemic treatments; 44% of patients continued on adalimumab despite having < 25% improvement in lesion count. CONCLUSION: UK dermatologists performed well against several audit standards, including documenting disease staging at baseline and smoking status. However, improvements are needed, particularly with regard to screening and management of comorbidities that could reduce the long-term complications associated with HS. A re-audit is required to evaluate changes in practice in the future.

Maternal care receptivity and its relation to perinatal and neonatal mortality. A rural study.

A longitudinal study was conducted on 212 pregnant women from May 1987 to April 1988. Maternal Care Receptivity (MCR) "an innovative approach" was adopted for the assessment of maternal care services provided to pregnant mothers at their door steps. During follow-up, scores were allotted to each of the services rendered and antenatal status of pregnant women. Depending on the score--MCR was classified as high (11 to 8), moderate (7 to 4) or poor (3 to 0). Perinatal and neonatal deaths were recorded and an inverse relationship between MCR and perinatal and mortalities was observed (z = 5.46, p < 0.0001). Significantly, no perinatal or neonatal deaths occurred in women with high MCR. One of the most important cause of high PNMR and neonatal mortality rate in developing countries is poor MCR, i.e., under utilization of even the existing maternal health services. The main reasons for this under utilization appear to be poverty, illiteracy, ignorance and lack of faith in modern medicine.

PIP: The receptivity of 212 pregnant women in rural Uttar Pradesh, India, to prenatal services provided at their homes was assessed during a May 1987 to April 1988 longitudinal study. The women, from four randomly selected villages, were assessed every month until completion of the neonatal period. Receptivity to doorstep prenatal services was calculated by developing a weighted score based on time when prenatal services began, frequency of visits accepted, number of doses of tetanus toxoid immunization accepted, and place of and person attending the delivery. Of the 212 women, 17% had poor, 75.9% had moderate, and 7.1% had high receptivity to the prenatal services. The pregnancies resulted in 5 stillbirths and 12 neonatal deaths before one week, for a perinatal mortality rate of 81.3/1000. 3 of the 8 infants who were in breech presentation died, 2 infants died from congenital defects, 2 from prematurity, 1 from cord prolapse, 1 from jaundice, 1 from fetal distress, and 2 from unknown causes. Another neonate died of meningitis. The perinatal mortality rates were 90.9, 86.9, and 0/1000 births in women with poor, moderate, and high receptivity scores, respectively. The inverse relationship between maternal care receptivity and the mortality rates was statistically significant. The poor receptivity to home-based prenatal care results from ignorance, illiteracy, and poverty and from a deeply rooted confidence in traditional birth attendants. This study also revealed that anemia persisted in 62.2% of these women even after iron and folic acid supplementation. This study highlights the importance of providing health education to pregnant women to increase their receptivity to maternal care services.

Non-small cell lung cancer: disease spectrum and management in a tertiary care hospital.

OBJECTIVES: To review the spectrum of presentation and the surgical management of Non Small Cell Lung Cancer (NSCLC) and the role of various diagnostic modalities in predicting the post-operative stage and the correlation of the post-operative stage with the chances of recurrence. SETTINGS: The Aga Khan University Hospital, Karachi--a tertiary care referral center in Paksitan. METHODS: This is a retrospective study of medical records of all the patients who were managed at the Aga Khan University Hospital (AKUH) between 1988 and 1998. The patients with a diagnosis of lung cancer were identified using the ICD-9-CM coding system and the data was analyzed for patients with NSCLC only. RESULTS: A total of 773 patients were admitted with a diagnosis of lung cancer at AKUH over 10 years period. Out of these 21 (2.71%) underwent staging mediastinoscopy and 20 (2.58%) patients underwent exploratory thoracotomy and biopsy without any resection, as the disease was found to be unresectable. Only 18 (2.32%) patients underwent surgical resection. There were 15 males and 3 females and the mean age was 53 years. Mean duration of symptoms was 12 months and cough and haemoptysis were the main presenting symptoms. Most of the tumors were located on the right side. CT scan and mediastinoscopy were mainly used to stage the disease. Complete surgical resection including en-bloc resection of adjacent structures was attempted, when possible. Median follow up was 24 months and the recurrence rate was 39%. There was no significant correlation between post-op stage and recurrence. CONCLUSION: It is concluded that most of the patients present at the advanced stage and resection is possible only in a small number of patients. The size of primary tumor and local extension should not contra-indicate surgery in patients with negative mediastinal nodes and without distant metastasis as it can be performed safely. All pulmonary lesion in the adults must be thoroughly investigated as early diagnosis and complete resection is the only key to cure and long term survival.

The use of intra aortic baloon pump in patients undergoing coronary artery bypass grafting at the Aga Khan University Hospital, Karachi.

OBJECTIVE: To review the experience in the use of Intra Aortic Balloon Pump (IABP) in patients undergoing Coronary Artery Bypass Grafting (CABG) at a tertiary care hospital with a new Open Heart surgery program. DESIGN: Retrospective study. SETTING: The Aga Khan University Hospital, Karachi. PATIENTS: Medical records of all patients undergoing CABG between November 1994 and July 1997 were reviewed and those in whom IABP device was used, were included in this study. RESULTS: A total of 15 patients had IABP support during the study period. Four surgeries were done urgently while two were emergencies. There were three mortalities. Ejection fractions in all but one patient were impaired. Among the surviving patients, the average pre-IABP Cardiac Index was 2.6 litres/min/meter2 which registered an average increase of 21.15% after the initiation of the IABP. The Pulmonary Artery Wedge Pressure also showed an average reduction of 29.11% from the pre IABP levels reflecting an increase in the cardiac output with the use of the IABP. CONCLUSION: This series represents the early experience of a new cardiac surgery center in Pakistan in the use of IABP. Although the numbers in this study are too small to derive any conclusions, the overall morbidity and mortality in this short series are within acceptable limits in the high risk patients included.

High perinatal and neonatal mortality in rural India.

A prospective study conducted in rural India on pregnant women showed poor utilization of primary health services and very poor maternal care receptivity especially in terms of antenatal care. A very high perinatal mortality rate of 81.3/1000 live births and a neonatal mortality rate of 63.7/1000 live births was observed in the present study. Out of 204 live births, 72.05% of newborn developed complications within 6 weeks of the delivery. Most of the complications were of a minor nature and could be attributed to poor environmental conditions, lack of personal hygiene and ignorance. The study highlights the need for training of grass root level workers for the improvement of perinatal and neonatal care in rural India.

PIP: In this study, the aim was to assess perinatal and neonatal mortality and morbidity in randomly selected villages of Oriya, Nagola, Rampur, and Chandokha in Aligarh District of Uttar Pradesh State, India. The population of 7541 received poor health services. A visit to all households within an 8 km distance netted 212 pregnant women between May 1987 and April 1988. Women were followed for a year; assessment included a routine clinical history and a general physical and obstetrical examination. Visits to the home included routine blood and urine tests. Cooperative mothers received a tetanus vaccine; calcium, iron, and folic acid tablets were distributed monthly during prenatal checkups. Daily visits were made during the postpartum period (6 weeks). Women were interviewed and information collected on their attitude, knowledge, and practice of existing health services and infant health. The results showed that transportation was an impediment to use of primary health services. Travel distance by foot to a bus stop was about 1-2 km. Considerable time was spent waiting for buses. 93% of the 212 illiterate and unaware of health care facilities. None of the women had used prenatal care in their prior pregnancies. There were 204 live births, of which 72.05% had complications within 6 weeks of the delivery. The conditions were conjunctivitis neonatorum (42.9%), "loose motions" (18.4%), and scabies/pyoderma (12.9%). 57% of the complications were due to poor hygiene or ignorance of the untrained Dai or female attendant. 10.9% of the cases were unavoidable. There were 17 perinatal deaths of which 5 were stillbirths (after 28 weeks gestation) and 12 were deaths at 1 week of age. 11 deaths were males (91.7/1000 total births) and 6 were females (67.4/1000 total births). The total rate was 81.3/1000 total births. There were 3 breech birth deaths, 2 from congenital defects, 2 from prematurity, a cord prolapse, a jaundice case, and fetal distress. 2 died of asphyxia neonatorum of unknown causes. The neonatal death rate was 63.7/1000 live births which is typical for rural areas in India. A community approach to health care, improvements in women's education, and grass roots level health personnel are recommended.

Anthropometric measurements in rural school children.

Anthropometric measurements of 1012 rural school-going children, selected randomly, were performed. There were 776 males and 236 females in the age group of 5-15 years. The values of weight and height were recorded for every child in the study sample. Age and sex break-up was studied and compared with the ICMR (Indian Council of Medical Research) standard. The comparison made separately for boys and girls showed that the values for both sexes and in all age groups were less than the ICMR standard. The majority (83.6%) of the children belonged to the middle and low social class according to the modified Prasad's classification. An inference is, therefore, drawn that rural school children of middle and low socio-economic status are shorter and lighter as compared with even their own counterparts on whom the ICMR values are based. The state of health of school-going children in India is far from satisfactory despite the fact that school health programmes along with other nutritional programmes have been in operation for several decades. School-going children constitute a sizeable section of India's population, i.e. about 27%, which is easily accessible and also receptive. An early and convenient method of assessing nutritional and socio-economic status of growing children is anthropometry. Physical growth, in terms of weight and height, is considered an important parameter reflecting the pattern of growth and development in a community. In the developing countries, the growing children by and large are deprived of good nutrition on account of their poor socio-economic status, ignorance and lack of health promotional facilities. This nutritional deprivation results in relative stunting of growth.

Isomerization of beta-HCH in aqueous solution.

beta-HCH was shaken with distilled water at 25 +/- 1 degree C for different time intervals and filtered. The ether extract of the filtrate on analysis by gas liquid chromatography showed the presence of four isomers, alpha, beta, gamma and delta, besides other compounds, thereby indicating isomerization of the beta-isomer in aqueous solution. Further, the ether extract, when dried and dissolved in acetone, showed high toxicity to mosquito larvae, flour beetle larvae and house-flies thereby indicating conversion of the inert beta-isomer to more toxic forms corroborating GLC analysis. Acetone solution of pure beta-HCH was found nontoxic against the insects tested.

Role of traditional birth attendants in maternal care services -- a rural study.

PIP: In India various programs have been launched to provide primary health care to women and children, particularly in the rural areas. However, the impact of these programs has not been significant. Though there is a provision of a trained dai (traditional birth attendant) in every village in the national program, most of the deliveries in rural areas are still conducted at home by untrained dais. This study was undertaken to find out about the decision of pregnant women in rural areas as regards the place of delivery and the nature of assistance received at delivery. Four villages in the Jawan Block, District of Aligarh, were randomly selected. All the villages were covered by the Integrated Child Development Services Scheme (ICDS). A total of 212 pregnant women were registered and each of them was contacted to inquire about the type of assistance received at delivery. 96.7% of the women were Hindus; 93.0% were illiterate and 68.5% were poor; 33.5% were high caste, 30.2% were low caste, and 30.2% were scheduled caste. Out of 212 deliveries, 205 (96.6%) were conducted at home. Assistance received at delivery (N = 212) was as follows: untrained dais (traditional birth attendants) 190 (89.6%); trained dais 0 (0.0%); prenatal care assistants 11 (5.2%); doctors 9 (4.2%); and relatives 2 (1.0%). The utilization of existing prenatal care services was meager, as the majority of pregnant women were illiterate and poor. As many as 205 (96.6%) deliveries were done at home. The finding that 89.6% deliveries were conducted by untrained dais assumes considerable significance in light of the fact that these villages of Jawan Block were among one of the first 3 ICDS blocks in Uttar Pradesh. This shows that there is still a wide gap between provision and utilization of maternal care services. Since most of the deliveries are conducted at home by untrained traditional birth attendants, the people must be educated to utilize the services of trained personnel.^ieng

Interconversions and toxicity changes in hexachlorocyclohexane isomers on dispersion in water.

Studies on the transformations of hexachlorocyclohexane isomers, alpha-, beta-, gamma- and delta-, in aqueous solution were carried out at 25 +/- 1 degree C over a period of four weeks. Gas liquid chromatographic technique was used for analysis. The results indicated a loss as well as interconversion of all the four isomers with time. The resulting changes in toxicity of the aqueous solution were studied against Drosophila using topical application. Toxicity studies with aqueous solution of technical hexachlorocyclohexane were simultaneously carried out for comparison. Toxicity of the aqueous solutions of alpha-, beta-, and delta- isomers showed an increase while that of the gamma- isomer decreased significantly during the four week experimental period. Aqueous solution of technical HCH was equally toxic as that of the gamma- isomer initially and did not show much decrease in its toxicity at the end. Changes in toxicity of the individual isomer solutions were considered to be due, in part, to interconversions of HCH isomers.