The Impact of Food Insecurity Rate on Bariatric Surgery Outcomes.

INTRODUCTION: Various factors impact outcomes following bariatric surgery. Lack of access to healthy food options (food insecurity [FI]) is another potential factor affecting outcomes. No prior studies have directly explored the relationship between residing in a high FI zip code and patient outcomes relating to weight loss after bariatric surgery. We hypothesized that living in a high FI zip code would be associated with decreased weight loss postsurgery. METHODS: We conducted a retrospective study with 210 bariatric surgery patients at a tertiary referral center from January to December 2020. Patient weight and body mass index (BMI) were recorded at three time points: surgery date, 1 mo, and 12 mo postoperative. Residential addresses were collected, and FI rates for the corresponding Zip Code Tabulation Areas were obtained from the 2022 Feeding America Map the Meal Gap study (2020 data). RESULTS: The FI rate showed a negative correlation of -18.3% (95% confidence interval: -35% to -0.5%; P = 0.039) with the percentage of excess weight loss (%EWL) at 1 y. In multivariate analysis, preoperative BMI (P = 0.001), presence of diabetes mellitus (P = 0.008), and bariatric procedure type (P = 0.000) were significant predictors of %EWL at 1 y. After adjusting for confounding factors, including sex, preoperative BMI, insurance status, primary bariatric procedure, and emergency department visits, the increased FI rate (P = 0.047) remained significantly associated with a decreased %EWL at 1 y. CONCLUSIONS: Residing in a high FI, Zip Code Tabulation Areas correlated with a decreased %EWL at 1 y after bariatric surgery. These findings highlight the importance of assessing FI status in pre-bariatric surgery patients and providing additional support to individuals facing FI.

Endoscopic closure techniques of bariatric surgery complications: a meta-analysis.

BACKGROUND: Leaks following bariatric surgery, while rare, are potentially fatal due to risk of peritonitis and sepsis. Anastomotic leaks and gastro-gastric fistulae following Roux-En-Y gastric bypass (RYGB) as well as staple line leaks after sleeve gastrectomy have historically been treated multimodally with surgical drainage, aggressive antibiotic therapy, and more recently, endoscopically. Endoscopic clipping using over-the-scope clips and endoscopic suturing are two of the most common approaches used to achieve full thickness closure. METHODS: A systematic literature search was performed in PubMed to identify articles on the use of endoscopic clipping or suturing for the treatment of leaks and fistulae following bariatric surgery. Studies focusing on stents, and those that incorporated multiple closure techniques simultaneously, were excluded. Literature review and meta-analysis were performed with the PRISMA guidelines. RESULTS: Five studies with 61 patients that underwent over-the-scope clip (OTSC) closure were included. The pooled proportion of successful closure across the studies was 81.1% (95% CI 67.3 to 91.7). The successful closure rates were homogeneous (I2 = 39%, p = 0.15). Three studies with 92 patients that underwent endoscopic suturing were included. The weighted pooled proportion of successful closure across the studies was shown to be 22.4% (95% CI 14.6 to 31.3). The successful closure rates were homogeneous (I2 = 0%, p = 0.44). Three of the studies, totaling 34 patients, examining OTSC deployment reported data for reintervention rate. The weighted pooled proportion of reintervention across the studies was 35.0% (95% CI 11.7 to 64.7). We noticed statistically significant heterogeneity (I2 = 68%, p = 0.04). One study, with 20 patients examining endoscopic suturing, reported rate of repeat intervention 60%. CONCLUSION: Observational reports show that patients managed with OTSC were more likely to experience healing of their defect than those managed with endoscopic suturing. Larger controlled studies comparing different closure devices for bariatric leaks should be carried out to better understand the ideal endoscopic approach to these complications.

Characteristics and kinetics of thermophilic actinomycetes' amylase production on agro-wastes and its application for ethanol fermentation.

Thermophilic actinomycetes are commonly found in extreme environments and can thrive and adapt to extreme conditions. These organisms exhibit substantial variation and garnered significant interest due to their remarkable enzymatic activities. This study evaluated the potential of Streptomyces griseorubens NBR14 and Nocardiopsis synnemataformans NBRM9 strains to produce thermo-stable amylase via submerged fermentation using wheat and bean straw. The Box-Behnken design was utilized to determine the optimum parameters for amylase biosynthesis. Subsequently, amylase underwent partial purification and characterization. Furthermore, the obtained hydrolysate was applied for ethanol fermentation using Saccharomyces cerevisiae. The optimal parameters for obtaining the highest amylase activity by NBR14 (7.72 U/mL) and NBRM9 (26.54 U/mL) strains were found to be 40 and 30 °C, pH values of 7, incubation time of 7 days, and substrate concentration (3 and 2 g/100 mL), respectively. The NBR14 and NBRM9 amylase were partially purified, resulting in specific activities of 251.15 and 144.84 U/mg, as well as purification factors of 3.91 and 2.69-fold, respectively. After partial purification, the amylase extracted from NBR14 and NBRM9 showed the highest activity level at pH values of 9 and 7 and temperatures of 50 and 60 °C, respectively. The findings also indicated that the maximum velocity (Vmax) for NBR14 and NBRM9 amylase were 57.80 and 59.88 U/mL, respectively, with Km constants of 1.39 and 1.479 mM. After 48 h, bioethanol was produced at concentrations of 5.95 mg/mL and 9.29 mg/mL from hydrolyzed wheat and bean straw, respectively, through fermentation with S. cerevisiae. Thermophilic actinomycetes and their α-amylase yield demonstrated promising potential for sustainable bio-ethanol production from agro-byproducts.

Prediction models in hernia repair: a systematic review.

BACKGROUND: Hernias can present with unique challenges when it comes to management and repair. Prediction models can be a useful tool for clinicians to better anticipate and understand the severity of a hernia, the type of surgical technique, or presurgical planning that may be required to treat the patient, and the risk of complications. Our goal is to evaluate and consolidate prediction models in hernia repair present in the literature for which physicians can reference to best improve patient outcomes and postoperative management. METHODS: We performed a literature search in PubMed using keywords, "rectus width to defect width ratio," "predicting myofascial release," "computed tomography hernia repair prediction," "component separation radiology prediction hernia," "fat volume and hernia repair," "body morphometrics and Query hernia repair," "body morphometrics and reherniation," "computed tomography findings and risk of emergency hernia repair," "loss of domain and hernia radiology," and "volumetry and hernia repair." We searched for publications that used radiographic parameters to predict hernia severity, interventions, and outcomes. RESULTS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), we found twenty-three studies related to prediction models in hernia repair published between 2000 and 2021. We summarized studies pertaining to predicting acute care, predicting operative planning with loss of domain and component separation, predicting complications, paraesophageal hernia predictions, and predicting postoperative respiratory complications. CONCLUSION: Radiographic prediction models can be an objective and efficient way for surgeons to analyze hernias and better understand a patient's situation so that they can inform patients about the best treatment options and the risk of complications.

Design and operation of a hybrid LED/LD-pumped phosphor-converted white-light lamp.

Illumination sources based on phosphors, pumped by laser diodes (LDs), have seen rapid developments over the past decade. Here, we present a new, to the best of our knowledge, design that features both spectral richness and the capability for high brightness. Complete design details and operational characterization have been described. This basic design can be extended in various ways to customize such lamps for different operational requirements. A hybrid arrangement of both LEDs and an LD is used to excite a mixture of two phosphors. The LEDs, in addition, provide a blue fill-in to enrich output radiation and to tune the chromaticity point inside the white region. The LD power, on the other hand, can be scaled up to generate very high brightness levels that are not achievable with pumping from LEDs alone. This capability is gained using a special transparent ceramic disk that carries the remote phosphor film. We also show that the radiation from our lamp is free from speckle-producing coherence.

Controlled-Potential-Based Electrochemical Sulfide Sensors: A Review.

Due to their potential applications in industry and potent toxicity to the environment, sulfides and their detection have attracted the attention of researchers. To date, a large number of controlled-potential techniques for electrochemical sulfide sensors have been developed, thanks to their simplicity, reasonable limit of detection (LOD), and good selectivity. Different researchers have applied different strategies for developing selective and sensitive sulfide sensors. However, there has been no systematic review on controlled-potential techniques for sulfide sensing. In light of this absence, the main aim of this review article is to summarize various strategies for detecting sulfide in different media. The efficiencies of the developed sulfide sensors for detecting sulfide in its various forms are determined, and the essential parameters, including sensing strategies, working electrodes, detection media, pH, LOD, sensitivity, and linear detection range, are emphasized in particular. Future research in this area is also recommended. It is expected that this review will act as a basis for further research on the fabrication of sulfide sensors for practical applications.

Characterisation of immunogenotypes of diffuse large B-cell lymphoma.

INTRODUCTION: Diffuse large B-cell lymphoma (DLBCL) is the most common aggressive type of non-Hodgkin lymphoma with variable clinical outcomes. The immunogenotypic features of this heterogeneous disease in Malaysia were not well characterized. MATERIALS & METHODS: In total 141 local series of DLBCL cases from UKM Medical Centre were retrospectively studied. RESULTS: Of these cases, we classified our patients into two subtypes: 32.7% (37/113) GCB and non-GCB 67.3% (76/113) by Hans algorithm and the results showed strong agreement with the results by Choi algorithm (κ = 0.828, P<0.001). Survival analysis indicated significant difference in between GCB and non-GCB subtypes (P=0.01), elevated serum LDH (P=0.016), age more than 60-year-old (P=0.021) and the presence of B symptoms (P=0.04). We observed 12% DLBCL cases were CD5 positive and 81.8% of them died of the disease (P=0.076). Analysis on the dual expression of MYC/BCL2 revealed that there is no significant difference in DE and non-DE groups (P=0.916). FISH study reported there were 9.22% (13/141) rearranged cases observed in our population at which highest frequency of BCL6 gene rearrangement (76.9%), followed by MYC (15.4%) and BCL2 (7.7%); no BCL10 and MALT-1 gene rearrangement found regardless of using TMAs or whole tissue samples. More cases of MYC protein overexpression observed compared to MYC translocation. CONCLUSION: Relatively lower frequency of GCB tumours and low gene rearrangement rates were observed in Malaysian population. A national study is therefore warranted to know better the immunogenotypic characteristics of DLBCL in Malaysia and their implications on the survival.

Impact of Adrenocortical Insufficiency on Biochemical Parameters in Haemodynamically Stable Cirrhotic Patients with Ascites.

Cirrhosis has many complications regardless of the aetiology. Among them, adrenal insufficiency is recently identified entity. A prospective cohort study was done to evaluate the biochemical impact of adrenocortical insufficiency in haemodynamically stable, non-septic, cirrhotic patients with ascites and had been performed at the inpatient of GHPD department, BIRDEM, Dhaka from April 2011 to March 2012. A total of fifty three (53) patients fulfilling inclusion criteria were included in the study. Patients were divided into two groups: Group A (patients of normal adrenal function) and Group B (patients of insufficient adrenal function) and those were followed up for the next 6 months. In Group A, the total number of patients was 25(47%) and in Group B it was 28(53%). Between two groups, mean age difference and gender difference were not statistically significant. (p value was 0.278 and 0.933, respectively). At enrollment, there was significant lower mean Hb concentration in Group B (p=0.008). There was no significant difference of means of WBC count and platelet count between two groups (p value was 0.829 and 0.333, respectively). There were significant abnormalities in serum bilirubin, serum albumin, INR, SBP, HRS, Serum Na concentration, TCO2 concentration in Group B patients at follow up after 6 months. Adrenal insufficient decompensated cirrhotic patients have higher biochemical abnormalities, thus higher morbidities.

Impact of Adrenocortical Insufficiency on Clinical Parameters in Haemodynamically Stable Cirrhotic Patients with Ascites.

Cirrhosis has many complications regardless of the aetiology. Complications include splenomegaly, ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, hepatorenal syndrome and hepatocellular carcinoma and also linked to abnormalities in the endocrine system, including abnormal sex hormone metabolism, thyroid disease, osteoporosis, and, most recently identified, adrenal insufficiency. This prospective cohort study was done to evaluate the impact of adrenocortical insufficiency on clinical parameters in haemodynamically stable cirrhotic patients with ascites and had been performed at the inpatient of GHPD Department, BIRDEM, Dhaka, Bangladesh from April 2011 to March 2012. A total of fifty three (53) patients fulfilling inclusion criteria were included in the study. Patients were divided into two groups: Group A (patients of normal adrenal function) and Group B (patients of insufficient adrenal function) and those were followed up for the next 6 months. In Group A, the total number of patients was 25(47%) and in Group B it was 28(53%). Between two groups, mean age difference and gender difference were not statistically significant (p value was 0.278 and 0.933, respectively). Group B patients had significant higher CLD duration (p=0.004). Haematemesis and/or maelena was significantly lower in Group B at follow up (p=0.0001) due to significant higher number of band ligation in this group (p=0.009). Hepatic encephalopathy was significantly higher in Group B at enrollment (p=0.028) and at follow up (p<0.001). During the period of follow up, significant higher number of patients had developed hepatic encephalopathy in Group B compared to Group A (p<0.05). There was statistically significant higher number of patients had SBP (p=0.031) in Group B at follow up. During the period of follow up, only 1(4%) patient in Group A and 5(18%) patients in Group B died. There was no significant difference of number of death between two groups (p=0.196). Adrenal insufficient decompensated cirrhotic patients have higher morbidities.

Prevalence of Psychiatric Disorders among Female Juvenile Offenders.

Inmates of Juvenile Developmental Centers are the special group of youth population who are in conflict with law. They are vulnerable to psychiatric illness. The objective of this study was to see the prevalence and type of psychiatric disorders in institutionalized female juvenile offenders and non-offenders of same age, sex and socioeconomic group in the community. The association of mental disorders was examined in 43 female inmates of Juvenile Development Centers and 43 randomly selected comparison subjects in community. One stage-structured assessment of psychopathology was carried out by using a structured and valid Bangla version of the Development and Well-Being Assessment (DAWBA). Development and Well-Being Assessment generated psychiatric diagnosis was assigned based on ICD-10 diagnostic criteria for research. The result revealed that, of those who were in conflict with law, 93% had mental disorder, whereas 14% of non-offenders had psychiatric disorder. Among the offenders with psychiatric disorders, most of them (32.6%) suffered from Major Depressive Disorder (MDD), followed by combined MDD & Post Traumatic Stress Disorder (PTSD). On the other hand, among the non-offenders with psychiatric disorder 9.3% suffered from MDD. It can be concluded that considerable psychiatric disorders are prevalent among the female juvenile offenders with comparison to non-offenders. Broad-based replication study could confirm these findings.

A Case Report on Percutaneous Coronary Intervention in Chronic Total Occlusion by Retrograde Visualization.

As bilateral approach is paramount in chronic total occlusions with retrograde flow, the use of two radial arteries, two femoral arteries or combination technique using one radial and one femoral artery will probably be increasingly reported in the near future. After puncture of opposite groin, a diagnostic 6 Fr catheter is used to intubate the ostium of the contralateral artery. By visualizing the distal vessel in multiple projections, contralateral injections help to direct the progression of the wire in the occluded segment towards the distal true lumen and confirm the intraluminal position of the wire after the occluded segment. We are reporting a case with chronic total occlusion where we used bilateral femoral access and simultaneous contrast injection to visualize retrograde flow in LAD while opening CTO through ante-grade pathway.

Radiation costing methods: a systematic review.

OBJECTIVE: Costs for radiation therapy (rt) and the methods used to cost rt are highly diverse across the literature. To date, no study has compared various costing methods in detail. Our objective was to perform a thorough review of the radiation costing literature to identify sources of costs and methods used. METHODS: A systematic review of Ovid medline, Ovid oldmedline, embase, Ovid HealthStar, and EconLit from 2005 to 23 March 2015 used search terms such as "radiation," "radiotherapy," "neoplasm," "cost," " cost analysis," and "cost benefit analysis" to locate relevant articles. Original papers were reviewed for detailed costing methods. Cost sources and methods were extracted for papers investigating rt modalities, including three-dimensional conformal rt (3D-crt), intensity-modulated rt (imrt), stereotactic body rt (sbrt), and brachytherapy (bt). All costs were translated into 2014 U.S. dollars. RESULTS: Most of the studies (91%) reported in the 33 articles retrieved provided rt costs from the health system perspective. The cost of rt ranged from US$2,687.87 to US$111,900.60 per treatment for imrt, followed by US$5,583.28 to US$90,055 for 3D-crt, US$10,544.22 to US$78,667.40 for bt, and US$6,520.58 to US$19,602.68 for sbrt. Cost drivers were professional or personnel costs and the cost of rt treatment. Most studies did not address the cost of rt equipment (85%) and institutional or facility costs (66%). CONCLUSIONS: Costing methods and sources were widely variable across studies, highlighting the need for consistency in the reporting of rt costs. More work to promote comparability and consistency across studies is needed.

The role of isohydric and anisohydric species in determining ecosystem-scale response to severe drought.

Ongoing shifts in the species composition of Eastern US forests necessitate the development of frameworks to explore how species-specific water-use strategies influence ecosystem-scale carbon (C) cycling during drought. Here, we develop a diagnostic framework to classify plant drought-response strategies along a continuum of isohydric to anisohydric regulation of leaf water potential (Ψ(L)). The framework is applied to a 3-year record of weekly leaf-level gas exchange and Ψ measurements collected in the Morgan-Monroe State Forest (Indiana, USA), where continuous observations of the net ecosystem exchange of CO2 (NEE) have been ongoing since 1999. A severe drought that occurred in the middle of the study period reduced the absolute magnitude of NEE by 55%, though species-specific responses to drought conditions varied. Oak species were characterized by anisohydric regulation of Ψ(L) that promoted static gas exchange throughout the study period. In contrast, Ψ(L) of the other canopy dominant species was more isohydric, which limited gas exchange during the drought. Ecosystem-scale estimates of NEE and gross ecosystem productivity derived by upscaling the leaf-level data agreed well with tower-based observations, and highlight how the fraction of isohydric and anisohydric species in forests can mediate net ecosystem C balance.

Measuring surgical performance: A risky game?

BACKGROUND: Interest in performance measurement has been driven by increased demand for better indicators of hospital quality of care. This is due in part to policy makers wishing to benchmark standards of care and implement quality improvements, and also by an increased demand for transparency and accountability. APPROACH: We describe the role of performance measurement, which is not only about quality improvement, but also serves as a guide in allocating resources within health systems, and between health, education, and social welfare systems. As hospital based healthcare is responsible for the most cost within the healthcare system, and treats the most severely ill of patients, it is no surprise that performance measurement has focused attention on hospital based care, and in particular on surgery, as an important means of improving quality and accountability. We are particularly concerned about the choice of mortality as an outcome measure in surgery, as this choice assumes that all mortality in surgery is preventable. In reality, as a low quality indicator of care it risks both gaming, and cream-skimming, unless accurate risk adjustment exists. Further concerns relate to the public reporting of this outcome measure. CONCLUSIONS: As mortality rates are an imperfect measure of quality, the reputation of individual surgeons will be threatened by the public release of this data. Significant effort should be made to communicate the results to the public in an appropriate manner.

Cause of and contributing factors to maternal deaths; a cross-sectional study using verbal autopsy in four districts in Bangladesh.

Verbal autopsy used at community level is an accepted method to identify cause of death and factors contributing to death. Maternal deaths occurring in four districts in Bangladesh over a period of 24 months were identified and community health workers were trained to conduct a verbal autopsy. Of 571 maternal deaths identified almost half (273, 47.8%) occurred at facility level, 97 (17.0%) died en route to a healthcare facility and 201 (35.2%) maternal deaths occurred at home. The majority of maternal deaths occurred in the postpartum period (78.8%) in the first 6 hours after giving birth (41.6% of all postpartum deaths). Women who had accessed care at a healthcare facility were less likely to die in the first 6 hours when compared with women who died at home (relative risk 0.70; 95% confidence interval 0.56-0.88) 70.4% (402) of deaths were classified as direct maternal deaths, 12.4% (71) as indirect and 13.8% (79) as unspecified. The most common cause of death was haemorrhage (38%), followed by eclampsia (20%) and sepsis (8.1%). Almost three out of four women who died had sought care for complications during the index pregnancy. Most mothers who died in Bangladesh had accessed care. It is now crucial that the quality of care received at health facility level is improved. This includes a refocus on strengthening healthcare providers' knowledge and skills to recognise and manage complications and provide emergency obstetric care. The enabling environment must be in place as well as ensuring a fully functional referral pathway between healthcare facilities.

SPECT-CT in total hip arthroplasty.

Single photon emission computed tomography combined with computed tomography (SPECT-CT), which combines functional and anatomical imaging, provides superior spatial localization to plain radiography and is more tolerant to metallic artefacts than conventional imaging such as magnetic resonance imaging (MRI). It is increasingly used in musculoskeletal imaging to enable accurate anatomical localization of increased tracer uptake, and is particularly useful in assessing metal prosthesis and the surrounding bone following total hip arthroplasty (THA). In addition to detecting complications of THA, SPECT-CT enables multiplanar reconstruction and manipulation of imaging data, which may aid surgical planning. SPECT-CT is an important adjunct to conventional imaging in the management of post-THA complications. It is vital that radiologists are able to identify the specific features of different complications and use this novel imaging technique to guide management. In this article, the use of SPECT-CT to follow post-THA complications, including aseptic loosening, periprosthetic infection, histiocytic reactions, periprosthetic fractures, polyethylene wear, and pseudotumour formation, will be reviewed.

Successful treatment of Erdheim-Chester disease with combination of interleukin-1-targeting drugs and high-dose glucocorticoids.

Erdheim-Chester disease (ECD) is a rare histocytic disorder. We report a case of a 45-year-old male ECD patient with severe clinical manifestation (urinary obstruction due to retroperitoneal mass with hydronephrosis, involvement of long bones) and central nervous system involvement (hemiparesis, aphasia and diabetes insipidus). Diagnosis was confirmed by typical clinical, radiological and histological findings. Under immunosuppressive therapy with prednisolone and interleukin-1A receptor antagonist (Anakinra, Kineret, Swedish Orphan Biovitrum AB, Stockholm, Sweden), a rapid improvement of the patients' symptoms and condition was observed. This is the first report of a successful combination therapy of Anakinra and glucocorticoids. Furthermore, current literature about ECD and treatment options are discussed.

[Drug-induced liver injury with an autoimmune phenotype following anti-TNF Therapy - presentation of cases and review of literature]. / Medikamentöse Schädigung der Leber mit autoimmunem Phänotyp durch TNF-Blockade - Fallvorstellung und Review der Literatur.

Therapeutic agents to inhibit tumour necrosis factor alpha (TNF-α) have dramatically improved the treatment options for patients with autoimmune diseases. Common side effects include an increased susceptibility towards infection. Hepatic side effects are less frequently observed. Elevated liver function tests, hyperbilirubinaemia reactivation of chronic viral hepatitis or even acute liver failure have been described. Some cases have exhibited an autoimmune phenotype with the emergence of autoantibodies and characteristic histological lesions. We report on three patients who received anti-TNF therapy for psoriasis and presented with elevated liver function tests in the further course. Histological and serum analysis revealed an autoimmune phenotype of liver injury. In light of the growing use of anti-TNF therapies, drug-induced liver injury (DILI) with an autoimmune phenotype is an important side effect. Since the pathophysiological mechanisms related to the autoimmune phenotype of liver injury during TNF-inhibition are not well understood, the cases detailed herein should help treating physicians to improve their understanding of the situation.

Tackling child health inequalities due to deprivation: using health equity audit to improve and monitor access to a community paediatric service.

BACKGROUND: Deprived children constitute a large population with high levels of ill health, and difficulty with access to healthcare contributes to their poor health outcomes. There is debate on how best to engage deprived families and the literature on differential access to paediatric care based on deprivation is limited. AIMS: To demonstrate that community paediatrics can contribute to reduction of health inequalities by providing services that are accessible to and preferentially used by children whose health is likely to be affected by deprivation. To provide a template for others to improve and monitor equity in their services. METHOD: Long-term service reconfiguration and health equity audit. We used routinely collected activity data and the Indices of Multiple Deprivation to construct equity profiles of the children using our service, and compared these with the profile of the population aged 0-16 years in the geographical area covered by the service. RESULTS: The new patient contact rate for the most deprived children in the population was more than three times that of the least deprived [odds ratio (OR) 3.29, 95% confidence interval (CI) 2.76-3.93]. Deprived children were more than twice as likely to require multi-agency meetings as part of their medical care (OR 2.28, 95% CI 1.94-2.69). Seventy per cent (3693/5312) of our total contacts were with children in the two most deprived quintiles. There was a marked socio-economic gradient in all types of contact. CONCLUSIONS: The model of care used by our community paediatric service successfully engages deprived families, thereby reducing health inequalities due to poor access. Key features are multi-agency working, removing barriers to access, raising staff awareness and use of health equity audit. Our findings provide support for tackling health inequalities via health services that are available to all, but capable of responding proportionately according to level of need, a model recently described as proportionate universalism.

Cutaneous anthrax in a school teacher.

Cutaneous anthrax is an infection of the skin caused by Bacillus anthracis. This is a report of a case of cutaneous anthrax attending outpatients of Mymensingh Medical College Hospital in October, 2010. The infected person was a retired school teacher with a very good body build. He reported to handle cow flesh about 4-5 days ago, developed few painless papules over shin of right leg, which gradually became large bullae and blackish eschar developed over the lesion. Smears from the lesions were investigated which confirmed the causative agent B. anthracis. The patient was treated with oral Ciprofloxacin (500mg) twice daily for seven days which cured the infection as observed on his subsequent follow up visits on 7 and 14 days later. Oral Ciprofloxacin is found effective as recommended by the World Health Organization.