Endarterectomy for asymptomatic carotid artery stenosis under local anaesthesia.

BACKGROUND: In this article, we present our experience with such operations performed under local anaesthesia. METHODS: From January 1997 to November 2007, there were 387 patients operated on for asymptomatic carotid stenosis. Patient data were retrospectively evaluated. Thirty-day neurological morbidity and mortality from six different subgroups were analysed and compared. The numbers of perioperative transient ischaemic attacks, as well as surgical and other perioperative complications were also evaluated. RESULTS: Overall morbidity and mortality was 1.8% (seven patients). Stroke was noted in 1.3% (five patients). Transitory ischaemic attacks within the first 30 days were observed in 1.6% (six patients). Only those patients who had intraluminal shunt insertion were found to have significantly higher morbidity and mortality. (p = 0.000018). Myocardial infarction was observed in 0.5% (two patients), one fatal. CONCLUSION: We have achieved acceptable morbidity and mortality rates (1.8%) according to the parameters set by previous studies such as Asymptomatic Carotid Atherosclerosis Study and Asymptomatic Carotid Stenosis Trial as well as American Heart Association and European Stroke Organisation guidelines. All surgeries were done under local anaesthesia. Shunts were inserted in 22 cases (5.68%).

A proposed vitamin A supplementation programme for South Africa--design, coverage and cost.

BACKGROUND: A national survey of the micronutrient status of preschool children in South Africa established that vitamin A deficiency is a significant public health problem, requiring urgent attention. A number of immediate and long-term interventions were recommended, including the introduction of a vitamin A supplementation programme and a food fortification programme. OBJECTIVES: The aim of the study was to assist in the development and implementation of a national vitamin A supplementation programme at primary health care facilities for mothers and children. This was achieved by determining the design, coverage and cost of a national primary health care facility vitamin A supplementation programme. METHODS: Based on an extensive review of the literature, the main components of a primary health care facility vitamin A supplementation programme were identified. The annual, recurrent costs of each of the programme components were estimated for the nine provinces in South Africa. Immunisation coverage rates were used as a proxy for estimating the coverage of the programme. RESULTS: The main components of the programme were identified as: promotion, training, purchase of vitamin A capsules, distribution of vitamin A capsules to primary health care facilities, distribution of capsules to the programme beneficiaries, and monitoring and evaluation. The programme would operate from primary health care facilities and would target all children between 6 and 24 months of age and newly delivered mothers. It was estimated that the programme would cover 74% of children and 95% of postpartum women nationally. The total annual, recurrent cost of the national programme was estimated at R16.4 million. The bulk of the costs would include personnel costs, comprising 68% of the total costs. Other costs included promotion (27%), vitamin A capsules (4%) and training (1%). The cost of the programme would vary significantly by province, but the provinces' average total cost per beneficiary would be similar. CONCLUSION: A primary health care facility vitamin A supplementation programme has been designed and accompanied by an estimated overall cost and coverage for implementation. The findings of the study showed that the programme would be financially feasible and would reach the majority of children under 24 months of age. It is recommended that further research be undertaken to extend the programme to the more 'hard to reach' population using other strategies such as mass immunisation campaigns.

Cost analysis as a vitamin A program design and evaluation tool: a case study of the Philippines.

Vitamin A deficiency (VAD) is a serious and widespread public health problem in the Philippines. Initiated in 1993, the Philippines National Vitamin A Supplementation Program (NVASP) is one of the oldest, most mature and comprehensive of its kind. This paper presents a cost-effectiveness and efficiency analysis of the NVASP and of a hypothetical program of vitamin A fortification of wheat flour that was conducted to inform policymakers as to how to modify the program. Employing a proxy effectiveness indicator of VAD--the intake of < 70% of the recommended daily allowance of vitamin A--in a series of simulations using individual child consumption data, the analysis finds that fortification is more efficient in reducing inadequate vitamin A intake (IVAI) compared to the NVASP. Due to the nature of food consumption patterns, however, fortification alone, is not enough. At what is regarded as the maximum politically acceptable fortification level, there will still be 2.2 million (29%) Filipino children aged 12-59 months who will have IVAI. An investigation of the cost and efficiency of geographically targeted supplementation programs reveals that maintaining a universal supplementation program in urban areas and, in rural areas, introducing a targeted program to only the poorest municipalities (where the prevalence of VAD is the highest) will provide a more acceptable public health policy response than fortification alone. Such a policy will reduce incremental direct Government expenditures on vitamin A programs by nearly 20% and will reduce the number of children with IVAI to 900,000 (12%) Filipino children. The paper describes the fortification and supplementation programs, and how their costs were estimated. Lessons for program designers and policymakers in other countries in which vitamin A deficiency constitutes a public health problem are also discussed.

The Nepal National Vitamin A Program: prototype to emulate or donor enclave?

More than 250 million of the world's children suffer from vitamin A deficiency. Nepal is one of 60 countries in which this deficiency constitutes a significant public health problem. Each year in Nepal, vitamin A deficiency is responsible for the deaths of 9000 children and for 2500 children becoming permanently blind. The Nepal National Vitamin A Program (NVAP) was begun in 1993 in eight of the country's 75 districts. By the end of 1997, the programme covered 32 districts, and by 2003 its coverage will be nationwide. The Nepal NVAP is considered by many to be a highly successful, model programme. It consists primarily of distributing high-dose vitamin A capsules to all children 6 to 60 months of age during twice-yearly campaigns. The capsule distribution is carried out by a previously existing network of Female Community Health Volunteers (FCHVs) that has been reinvigorated by the highly visible and universally acclaimed success of the NVAP. An important strategy of the programme has been the empowerment of the FCHVs, which has been accomplished by organizing, training and motivating community workers and other representatives from education, agriculture and other sectors, as well as political representatives, to support the FCHVs. The annual cost of the NVAP is US$1.7 million. It costs $1.25 to deliver two vitamin A capsules to each participant. The cost per averted death is $327. The NVAP reduces the incidence and severity of diarrhoeal disease and measles, which in turn reduces the need for Ministry of Health services, thereby annually saving the Government of Nepal $1.5 million. Factoring in these cost savings, the net annual cost of the current NVAP is $167,000, and the net annual cost of the permanent, nationwide programme is estimated at $1.1 million. The NVAP is a highly cost-effective programme. The article concludes with a discussion of the sustainability and replicability of the programme.

The costs and effectiveness of three vitamin A interventions in Guatemala.

The purpose of the study presented in this paper was to estimate, using secondary sources of data, the cost and effectiveness of three programs to combat vitamin A deficiency in Guatemala-the national sugar fortification program, a targeted capsules distribution program and the promotion of home food production combined with nutrition education and to draw conclusions concerning priorities for Guatemala. Data on the costs and coverage were collected from implementing agencies in Guatemala. Coverage data were converted into a common set of impact indicators. Sensitivity analyses were conducted on variables whose precise value was uncertain. Potential impacts of improvements in program performance operations were also explored. The analysis found the cost per high-risk person achieving adequate vitamin A to be US $0.98 for fortification, US $1.68-1.86 for capsule distribution and US $3.10-4.16 for food production/education. Fortification is the most efficient option if vitamin A levels in sugar are maintained at reasonable levels. Where fortified sugar is not consumed and vitamin A deficiency is highly prevalent, small-scale, targeted, complementary interventions such as capsules and food production education may be appropriate for sustained broader impacts.

Cyanide sensitive and insensitive bioenergetics in a clonal neuroblastoma x glioma hybrid cell line.

The primary mechanism of cyanide (CN) intoxication is the inhibition of metabolism in the central nervous system. We determined the effects of CN on several biochemical processes in neuroblastoma x glioma hybrid NG108-15 cells, which possess numerous neuronal properties. These cells were not sensitive to a high concentration (1 mM) of NaCN, but became sensitive in the presence of the anaerobic glycolysis inhibitors sodium iodoacetate (IA) and 2-deoxyglucose (2-DG):cellular metabolic processes (e.g., DNA, RNA and protein synthesis) decreased to about 40% of control due to treatment with 0.5 mM NaCN + 0.05 mM IA and 0.1 mM NaCN + 20 mM 2-DG. ATP in cells exposed to 0.01 or 0.1 mM NaCN + 20 mM 2-DG was reduced 75% and 100% respectively within one min. Pretreatment of cells with the CN antidote cobalt (II) chloride (CoCl2) (0.06-0.18 mM) for 5 min prevented the depression of both [3H]leucine incorporation and ATP synthesis due to 1 mM NaCN + 20 mM 2-DG in a concentration-dependent manner. A proposed CN antidote alpha-ketoglutaric acid (disodium salt) also prevented the depression of cellular metabolism due to NaCN plus 2-DG. These results indicate that blocking anaerobic glycolysis makes NG108-15 cells sensitive to a low concentration of CN. Thus NG108-15 cells should be useful to study the mechanisms of neurotoxicity of CN and to test antidotes.

Clinical and economic impact of oral ciprofloxacin as follow-up to parenteral antibiotics.

This study assessed the effects of switching to ciprofloxacin hydrochloride in patients initially treated with parenteral antibiotics for respiratory tract (RTI), skin or skin structure (SSS), bone or joint (BJI), or urinary tract infection (UTI). A total of 766 patients from 54 institutions were concurrently monitored and the projected effect of ciprofloxacin on duration of hospitalization and parenteral therapy was assessed based on previous experiences with each type of patient. The median duration of parenteral antibiotic therapy prior to oral ciprofloxacin was 4, 6, 6, and 7.5 days; the median duration of oral ciprofloxacin prior to discharge was 2, 2, 2, and 4 days for UTI, RTI, SSS, and BJI, respectively. It was estimated that more than 70 percent of patients would have continued parenteral antibiotics on an inpatient basis and only 10 percent would have received an alternative oral agent if ciprofloxacin were not available. Use of oral ciprofloxacin significantly affected both duration of parenteral therapy and duration of hospitalization. It was estimated that 16,732 doses of parenteral antibiotics were avoided and, after subtracting the cost of oral ciprofloxacin, resulted in a likely net savings of $187 146.50. An estimated total of 2266 hospital days were saved in 418 patients, resulting in estimated savings of $739 100. Total drug plus hospitalization cost savings were projected to be $980 246.50. Further research is required to determine if, and where, more aggressive intervention will achieve additional cost savings.

[Rapid glutamic acid decarboxylase test for identification of Escherichia coli]. / Glutaminsäuredecarboxylase-Schnelltest zur Identifikation von Escherichia coli.

A rapid, one-step glutamic acid decarboxylase test for the identification of Escherichia coli is described. The test gives a positive reaction (definite blue color) after 2 h to 3 h. Disturbing factors were explained. Microorganisms were cultured to Endo agar (SIFIN) supplemented with 1% meat peptone (Berlin-Chemie). For rapid liberation of the enzyme a combination of lytic agents NaCl and Triton X-100 were necessary. A total of 6,867 strains of Enterobacteriaceae of clinically isolates were parallely tested to activity of lactose, indole, citrate respectively biochemical tests with 15 reactions on the one side and activity of lactose and glutamic acid decarboxylase on the other side. 99.2% of the E. coli strains gave a positive reaction with glutamic acid decarboxylase. The rapid test selected E. coli with more reliability than the combination of the lactose, indole and citrate reactions. Expenditure of time and materials was fewer.