The development and evaluation of a community-based clinical diagnosis tool and treatment regimen for postpartum sepsis in Bangladesh and Pakistan.

BACKGROUND: Postpartum sepsis accounts for most maternal deaths between three and seven days postpartum, when most mothers, even those who deliver in facilities, are at home. Case fatality rates for untreated women are very high. Newborns of ill women have substantially higher infection risk. METHODS/DESIGN: The objectives of this study are to: (1) create, field-test and validate a tool for community health workers to improve diagnostic accuracy of suspected puerperal sepsis; (2) measure incidence and identify associated risk factors and; (3) describe etiologic agents responsible and antibacterial susceptibility patterns. This prospective cohort study builds on the Aetiology of Neonatal Infection in South Asia study in three sites: Sylhet, Bangladesh and Karachi and Matiari, Pakistan. Formative research determined local knowledge of symptoms and signs of postpartum sepsis, and a systematic literature review was conducted to design a diagnostic tool for community health workers to use during ten postpartum home visits. Suspected postpartum sepsis cases were referred to study physicians for independent assessment, which permitted validation of the tool. Clinical specimens, including urine, blood, and endometrial material, were collected for etiologic assessment and antibiotic sensitivity. All women with puerperal sepsis were given appropriate antibiotics. DISCUSSION: This is the first large population-based study to expand community-based surveillance for diagnoses, referral and treatment of newborn sepsis to include maternal postpartum sepsis. Study activities will lead to development and validation of a diagnostic tool for use by community health workers in resource-poor countries. Understanding the epidemiology and microbiology of postpartum sepsis will inform prevention and treatment strategies and improve understanding of linkages between maternal and neonatal infections.

Use of clinical guidelines: perspectives from clinicians in paediatric and maternity hospitals in Kabul, Afghanistan.

This study explored the perceived value, role and reported use of clinical guidelines by clinicians in urban paediatric and maternity hospital settings, and the effect of current implementation strategies on clinician attitudes, knowledge and behaviour. A total of 63 clinicians from 7 paediatric and maternity hospitals in Kabul, Afghanistan participated in structured focus groups; content analysis methodology was used for identification and analysis of key themes. Seven sets of guidelines, protocols or standards were identified (including 5 WHO-endorsed guidelines). However, most are failing to achieve high levels of use. Factors associated with guideline use included: clinician involvement in guideline development; multidisciplinary training; demonstrable results; and positive clinician perceptions regarding guideline quality and contextual appropriateness. Implementation activities should fulfil 3 major objectives: promote guideline awareness and access; stimulate motivation among clinical guideline users; and actively facilitate adherence to guidelines.

Harmonic scalpel compared with conventional excisional haemorrhoidectomy: a meta-analysis of randomized controlled trials.

BACKGROUND: Haemorrhoidectomy is the most effective and definitive treatment for grade 3 or 4 haemorrhoids despite being associated with considerable pain. The aim of this study was to search the literature, which compares outcomes of harmonic scalpel haemorrhoidectomy and traditional surgical procedures, and conduct a quantitative meta-analysis of the randomized trials. METHODS: Randomized controlled trials (RCTs) were identified from the major electronic databases using the keywords "harmonic scalpel haemorrhoidectomy" and "haemorrhoidectomy" and a quantitative meta-analysis conducted. The eight trials that met the inclusion criteria included 468 patients (233 in the harmonic scalpel group). Pain was the primary outcome measure, and other parameters assessed included duration of operation, length of hospital stay, time to return to work, and complications. RESULTS: Significantly, more patients returned to work in the first post-operative week, and pain scores were an average of one unit lower following harmonic scalpel haemorrhoidectomy. Generally, the incidence of complications in the harmonic scalpel group was less than half that found in conventional haemorrhoidectomy. There was no significant difference between the groups as regards operating time or length of hospital stay. Recurrence was not reported in any of the studies. CONCLUSIONS: The meta-analysis showed that harmonic scalpel haemorrhoidectomy is a safe and effective modality associated with less post-operative pain and a more rapid return to work than traditional surgery for haemorrhoids. Statistical heterogeneity was high; thus, it may be too early to place complete confidence in these results. Further RCTs are required.

Biofeedback therapy for symptoms of bowel dysfunction following surgery for colorectal cancer.

BACKGROUND: Following colorectal cancer (CRC) surgery, up to 60% of patients experience post-surgery bowel dysfunction (PSBD). This retrospective review aimed to evaluate biofeedback therapy with regard to patients' symptoms of fecal incontinence (FI) and stool frequency. METHODS: Patients with symptoms including frequency, urgency, FI, incomplete evacuation, failure to respond to dietary, medication or standard pelvic floor exercises (≥ 6 months) underwent biofeedback therapy between 2003 and 2006. Patients attended 3-4 sessions 1 week apart incorporating: anorectal function assessment; Fecal Incontinence Quality of Life (FIQL) and severity questionnaires; suggested coping strategies; dietary advice; bowel, food and exercise diary training; relaxation breathing; evacuation techniques; anal and pelvic floor muscle exercises using computerized visual feedback; and were reassessed at a final session following 4 weeks of home practice. RESULTS: Nineteen CRC PSBD patients [anterior resection (3); ultra-low anterior resection (10); segmental colectomy (2); and proctocolectomy (4)], mean age: 64.1 (95% CI: 47.0-81.3) years, participated. FIQL scales improved significantly for lifestyle, coping and embarrassment but not depression. Incontinence severity and number of bowel motions significantly decreased. Satisfaction with results of therapy was high. Subjective bowel control rating improved. FIQL scores further improved 2 years later. CONCLUSION: The holistic biofeedback protocol for PSBD in CRC patients is successful in the short and medium term.

Biofeedback therapy for faecal incontinence: a rural and regional perspective.

INTRODUCTION: Faecal incontinence is the involuntary loss of liquid or solid stool with or without the patient's awareness. It affects 8-11% of Australian community dwelling adults and up to 72% of nursing home residents with symptoms causing embarrassment, loss of self-respect and possible withdrawal from normal daily activities. Biofeedback, a technique used to increase patient awareness of physiological processes not normally considered to be under voluntary control, is a safe, conservative first-line therapy that has been shown to reduce symptom severity and improve patient quality of life. The Townsville Hospital, a publicly funded regional hospital with a large rural catchment area, offers anorectal biofeedback for patients with faecal incontinence, constipation and chronic pelvic pain. The aim of this report is to describe the effect of the biofeedback treatment on the wellbeing of regional and rural participants in a study of biofeedback treatment for faecal incontinence in the Townsville Hospital clinic. METHODS: There were 53 regional (14 male) and 19 rural (5 male) participants (mean age 62.1 years) enrolled in a biofeedback study between January 2005 and October 2006. The program included 4 sessions one week apart, 4 weeks home practice of techniques learnt and a final follow-up reassessment session. Session one included documenting relevant history, diet, fibre, and fluid intake and treatment goals; anorectal function and proctometrographic measurements were assessed. Patients were taught relaxation (diaphragmatic) breathing in session two with a rectal probe and the balloon inserted, prior to inflating the balloon to sensory threshold. In session three, patients were taught anal sphincter and pelvic floor exercises linking the changes in anal pressures seen on the computer monitor with the exercises performed and sensations felt. Session four included improving anal and pelvic floor exercises, learning a defecation technique and receiving instructions for 4 weeks home practice. At the fifth session, home practice and bowel charts were reviewed and anorectal function was reassessed. Symptom severity and quality of life were assessed by surveying participants prior to sessions one and two and following session five. Patients were interviewed after session five to determine their satisfaction with the therapy and the helpfulness of individual program components. They were mailed a follow-up survey 2 years later. RESULTS: Regional participants lived within 30 min drive of the clinic (median distance 8 km) while rural participants travelled up to 903 km (median 339 km, p<0.001) to attend the clinic. Faecal Incontinence risk factors were similar for rural and regional participants. Rural participants reported poorer general health (p=0.004) and their symptoms affected their lifestyle more negatively (p=0.028). Participants' incontinence (p<0.001) and quality of life (p<0.001) improved significantly over the treatment period. Improvement for rural participants over the course of treatment was marginally better than that of regional participants, although not significantly. More than 97% of patients reported that the biofeedback program was very/extremely helpful and all participants attending the final session reported that they would advise a friend in a similar situation not to wait, but seek help immediately, with more than half specifically citing the biofeedback program. Two years later regional participants' symptoms and quality of life continued to improve while rural participants' quality of life had regressed to pre-treatment levels. CONCLUSIONS: For equivalent long term improvement in faecal continence and quality of life to be achieved in both regional and rural participants, an additional follow-up session with the biofeedback therapist, ongoing local support provided by continence advisors, or both, should be investigated for rural patients.

PTQ anal implants for the treatment of faecal incontinence.

BACKGROUND: In North Queensland demand for conservative faecal incontinence treatments outweighs supply. Injectable bulking agents offer a safe and effective treatment for patients with internal anal sphincter (IAS) dysfunction. METHODS: Information, including age and sex, baseline incontinence score, quality of life, resting and squeeze pressures, was collected for 74 patients (37 men) who received intersphincteric PTQ injections. Postimplant satisfaction was assessed at 6-week review. Incontinence scores and satisfaction ratings were determined annually. RESULTS: At a median follow-up of 28 months, 52 patients (70 per cent) with IAS dysfunction who received PTQ anal implants as a treatment for faecal incontinence were continent and extremely satisfied with the result. The incontinence score in participants who remained incontinent was reduced significantly from 12 of 20 before implant to 3.5 of 20 at follow-up (P < 0.001). Migration rates improved with experience. The poorest results occurred in women with pudendal neuropathy, or patients who had previously received biofeedback treatment. CONCLUSION: Implanted PTQ provides an effective solution to faecal incontinence in the short and mid term for patients with IAS dysfunction.

Dopaminergic reinnervation of the globus pallidus by fetal nigral grafts in the rodent model of Parkinson's disease.

The current neural transplantation strategy for Parkinson's disease (PD) involves the dopaminergic reinnervation of the striatum (STR). Although up to 85% reinnervation of the STR has been attained by neural transplantation, functional recovery in animal models and transplanted patients is incomplete. This limitation may be due to an incomplete restoration of the dopaminergic input to other basal ganglia structures such as the external segment of the globus pallidus (GPe, homologue of the rodent GP), which normally receives dopaminergic input from the substantia nigra (SN). As part of our investigation into a multiple grafting strategy for PD, we have explored the effects of dopaminergic grafts in the GP of rodents with unilateral 6-hydroxydopamine (6-OHDA) lesions. In this experiment, lesioned rats received either 300,000 fetal ventral mesencephalic (FVM) cells or a sham injection into the GP. Functional assessment consisted of rotational behavior at 3 and 6 weeks posttransplantation. A fluorogold tracer study was conducted to rule out any behavioral improvement due to striatal outgrowth of the GP graft. Sections were stained for glial fibrillary acidic protein (GFAP) to assess the degree of trauma in the GP by the graft in comparison to the sham injection. Immunohistochemistry for tyrosine hydroxylase (TH) was performed after transplantation to assess graft survival. Animals with GP grafts demonstrated a significant improvement in rotational behavior at 3 and 6 weeks posttransplantation (p < 0.05) while sham control animals did not improve. All animals receiving FVM cells showed TH-immunoreactive grafts in the GP posttransplantation. TH-positive neurons in the GP showed no double labeling with an intrastriatal injection of fluorogold, indicating that behavioral improvement was not due to striatal innervation by the GP graft. These observations suggest that functional recovery was the result of dopaminergic reinnervation of the GP and that this nucleus may be a potential target for neural transplantation in clinical PD.

The formulation of recombinant factor IX: stability, robustness, and convenience.

A lyophilized recombinant factor IX (rFIX) formulation has been developed that is stable and contains no preservatives. No blood or plasma products are used in the production or formulation of rFIX. The formulation contains 10 mmol/L histidine, 0.26 mol/L glycine, 1% sucrose, and 0.005% polysorbate-80 (pH 6.8). Polysorbate-80 acts as a protectant for the protein from freezing-induced damage (eg, aggregation). Sucrose provides protection to the protein in the freeze-dried state. Glycine provides for a high-quality cake morphology. Histidine provides optimal buffering stability at the desired pH and minimizes aggregate formation upon storage in the lyophilized state. This optimized combination of excipients provides a high degree of long-term stability, as demonstrated by a variety of analytical methods, including clotting assays, sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE), isoelectric focusing (IEF), size-exclusion chromatography (SEC), peptide mapping, oligosaccharide fingerprinting, and reverse-phase high-performance liquid chromatography (HPLC). The rFIX product is easy to reconstitute and demonstrates excellent stability in solution after reconstitution.

The use of APACHE II scores to select candidates for left ventricular assist device placement. Acute Physiology and Chronic Health Evaluation.

BACKGROUND: The growth in left ventricular assist device (LVAD) use has been hampered by high morbidity and mortality rates and cost. The purpose of this study was to help improve patient selection for LVAD placement by determining whether the Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system, a multiparameter, physiology-based predictor of outcome, could be used to predict outcome after LVAD placement and thus help determine optimum timing of LVAD placement. METHODS: This was a retrospective analysis of a prospective cohort observational study consisting of 2 groups: (1) 50 patients with severe heart failure who did not receive LVAD placement after initial evaluation and (2) 31 patients who did receive LVAD placement. Patients included in the study were in severe heart failure on the basis of 3 of the following: lung crackles, S3, peripheral edema, ejection fraction < 0.30, systolic blood pressure < 80 mm Hg, progressive prerenal azotemia, altered level of consciousness, gastrointestinal ischemia or congestion, or persistent although reversible pulmonary hypertension in spite of maximal medical therapy, including intravenous inotropes. The decision for LVAD placement was at the discretion of the attending physician. RESULTS: Both LVAD- and non-LVAD-treated patients were similar in cause of heart failure, APACHE II scores, and other baseline laboratory parameters. Survival time with a log-logistic model was better for LVAD-treated patients, p=.0266. Although Kaplan Meier analysis showed a trend toward better survival rates in the LVAD-treated patient, the Cox proportional hazards revealed that LVAD-treated patients had better survival (relative risk ratio, 95% confidence interval=0.305, 0.110 to 0.892; p=.0219) after adjustment for APACHE II score. Each unit increase in APACHE II independently predicted death (relative risk ratios, 95% confidence interval=1.139, 1.055 to 1.231; p=.0009). Patients with medium APACHE II (11 to 20) scores in particular benefitted from LVAD treatment. CONCLUSION: LVAD placement for severe heart failure (not restricted to cardiogenic shock) improves survival. APACHE II can aid in deciding the timing of LVAD placement in patients with heart failure who may not have attained conventional hemodynamic criteria for LVAD placement. Patients who had APACHE II scores between 11 and 20 derived the greatest benefit from LVAD placement.

Chronic cardiac rejection masking as constrictive pericarditis.

The hemodynamic changes consistent with constrictive pericarditis are often encountered in patients who have undergone cardiac transplantation. We describe here 4 patients who underwent pericardiectomy after cardiac transplantation. All were found to have evidence of a thickened and constricting peel of pericardium at surgical exploration. Their postoperative clinical courses were variable. One patient with primarily effusive constriction experienced marked improvement. Three patients failed to show clinical improvement and had persistently elevated atrial and ventricular end-diastolic pressures. A coexisting restrictive cardiomyopathy secondary to chronic rejection, coronary arteriopathy, or long-standing constriction may have been the cause of this poor outcome. Many patients with transplanted hearts exhibit evidence of poor diastolic ventricular compliance without evidence of classic constriction; some manifest both the restrictive and constrictive components. The careful selection of patients with constrictive pericarditis can optimize the outcome.

Prognostic factors in fresh water immersion.

The records of 63 consecutive fresh water immersion patients seen from 1969 to 1978 were examined retrospectively to evaluate those factors most relevant to the patients' eventual outcome. Nineteen patients had hematuria on admission, all 19 had complicated courses or died as a result of their immersion. Nine of the 63 patients had plasma hemoglobin concentrations of 30 mg/dl or above. Five of the nine died as a result of their immersion. The remaining four developed Adult Respiratory Distress Syndrome but survived. All other parameters measured seemed to have little effect on the prognosis. An elevation of PCO2 on admission seemed difficult to evaluate but might in certain circumstances suggest an ominous prognosis.

Measurement of upper extremity torque production and its relationship to throwing speed in the competitive athlete.

This study was conducted to establish whether or not a correlation exists between peak torque production of upper extremity (UE) musculature and throwing speed. Eleven professional baseball players were tested for upper extremity peak torque production using a Cybex II Isokinetic Dynamometer. Throwing speed was measured with a radar gun. Results of statistical analysis performed on the data indicate a correlation between shoulder adductors and throwing speed.

Rates of sexually transmitted diseases among patients in a psychiatric emergency service.

OBJECTIVE: This study sought to estimate the prevalence of non-HIV sexually transmitted diseases among patients admitted to a psychiatric emergency service and to identify characteristics that might place members of this population at increased risk of acquiring these diseases. METHODS: Hospital medical records and records of public health departments' venereal disease control sections were retrospectively reviewed to determine if patients consecutively admitted to a psychiatric emergency service at a large urban public hospital had been tested for syphilis, gonorrhea, trichomonas, chlamydia, or herpes simplex in the 12 months before admission and whether the tests were positive. Data on patients' demographic and clinical characteristics were also collected. RESULTS: Of 426 consecutive patients studied, 214 (50.2 percent) were tested for one or more non-HIV sexually transmitted diseases. Forty of those patients (18.7 percent) had positive tests. The rates of syphilis and gonorrhea among the patients were significantly higher than those estimated for the city and state where the study was done and significantly higher than the national estimate. Patients whose tests were positive did not differ significantly from those with negative tests in presenting psychiatric symptoms or diagnosis. CONCLUSIONS: An alarmingly high rate of non-HIV sexually transmitted diseases was found among patients treated in a psychiatric emergency service. However, no particular clinical subpopulations at increased risk for acquisition of these diseases could be identified.

Inflammatory pseudotumour of the central nervous system: clinicopathological study of one case and review of the literature.

A 58-year-old male who had been diagnosed as having polymyositis was found to have a mass in the fourth ventricle. This mass showed features of an inflammatory pseudotumour. This lesion has been described in many parts of the body including the central nervous system. This case showed some features different from the previously reported cases in the central nervous system (i.e. presence of necrosis and association with polymyositis) which may throw some light on the pathogenesis of the condition. Inflammatory pseudotumour is most likely to be caused by an exaggerated immunological process and is sometimes associated with high levels of serum immunoglobulin.

Disciplining handicapped students: legal issues in light of Honig v. Doe.

Court decisions interpreting the effect of the education for All Handicapped children Act on traditional forms of public school discipline have raised many question. This article reviews these decisions and confirms that most forms of minor disciplinary remedies remain available to educators so long as they are also used with nonhandicapped students. However, many legal problems arise with expulsion and long-term, or indefinite, suspensions of handicapped students, especially in the light of the recent Supreme court ruling regarding the expulsion of handicapped students.