The effect of botulinum toxin A in unilateral cleft lip scar: comparison of results with different sites of injection.

Botulinum toxin type A (BTA) injections into the subjacent orbicularis oris muscle have been shown to improve appearance and produce narrower cheiloplasty scars. This study was performed to determine the effect of BTA injected at different sites on the unilateral cleft lip scar and cleft side nostril width. A double-blind, randomized prospective trial was conducted involving 64 consecutive patients with unilateral cleft lip undergoing primary cheiloplasty between September 2016 and January 2019. The patients were randomized to receive BTA injections either into the subjacent orbicularis oris muscle (4 points group) or into the bilateral nasolabial fold region (6 points group) during cheiloplasty. The scars were assessed by photographic scar width measurements and Vancouver scar scale assessment tool. The cleft side nostril width was compared to the non-cleft side width. Fifty-six patients completed the trial, 24 in the 4 points group and 31 in the 6 points group. There was no significant difference in scar width or nostril width measurements between the groups at the end of follow-up. The Vancouver scar scale assessment was also similar between the groups. There was no significant difference in scar width or nostril width measurements after cleft lip repair between patients treated with botulinum toxin injections to the subjacent orbicularis oris muscle and patients treated with injections in the nasolabial region.

Non-response to first-line anti-tuberculosis treatment in Sikkim, India: a risk-factor analysis study.

Setting: Sikkim, India, has the highest proportion of tuberculosis (TB) patients on first-line anti-tuberculosis regimens with the outcome 'failure' or 'shifted to regimen for multidrug-resistant TB (MDR-TB)'. Objective: To assess the factors associated with non-response to treatment, i.e., 'failure' or 'shifted to MDR-TB regimen'. Methods: We conducted a retrospective cohort study using Revised National Tuberculosis Control Programme data of all TB patients registered in 2015 for first-line TB treatment. In addition, we interviewed 42 patients who had not responded to treatment to ascertain their current status. Results: Of 1508 patients enrolled for treatment, about 9% were classified as non-response to treatment. Patient factors associated with non-response were urban setting (adjusted odds ratio [aOR] 2.39, 95%CI 1.22-4.67), ethnicity (being an Indian tribal, aOR 1.73, 95%CI 1.17-2.57, Indian [other] aOR 1.83, 95%CI 1.29-2.60 compared to patients of Nepali origin) and those on retreatment (aOR 2.40, 95%CI 1.99-2.91). Of the patients interviewed, 28 (67%) had received treatment for drug-resistant TB. Conclusion: In Sikkim, one in 11 patients had not responded to first-line anti-tuberculosis treatment. Host-pathogen genetics and socio-behavioural studies may be required to understand the reasons for the differences in non-response, particularly among ethnic groups.

Contexte : L'état de Sikkim, en Inde, a la proportion la plus élevée du pays de patients atteints de tuberculose (TB) sous protocole antituberculeux de première ligne avec pour résultats « échec ¼ ou « passé à un protocole de TB multirésistante (TB-MDR) ¼.Objectif : Evaluer les facteurs associés à une non réponse au traitement (« échec ¼ ou « passé à un protocole de TB-MDR¼).Méthode : Nous avons réalisé une étude rétrospective de cohorte grâce aux données du programme national révisé pour la lutte contre la tuberculose de tous les patients TB enregistrés en 2015 pour un traitement de TB de première ligne. Nous avons également interviewé 42 patients ayant une non réponse au traitement pour vérifier leur statut actuel.Résultats : Sur les 1508 patients enrôlés en traitement, environ 9% ont été classés comme non réponse au traitement. Les facteurs liés au patient associés à l'absence de réponse ont été un contexte urbain (odds ratio ajusté [ORa] 2,39 ; IC95% 1,22­4,67), l'ethnicité (appartenance à une tribu Indienne, ORa 1,73 ; IC95% 1,17­2,57, autres populations Indiennes, ORa 1,83 ; IC95% 1,29­2,60, par comparaison aux patients d'origine Népalaise) et aux patients en retraitement de TB (ORa 2,40 ; IC95% 1,99­2,91). Parmi les patients interrogés, 28 (67%) ont reçu un traitement pour TB pharmacorésistante.Conclusion : Au Sikkim, un patient sur 11 avait une non réponse au traitement antituberculeux de première ligne. Des études de génétique hôte-pathogène et des études sociocomportementales pourraient être requises afin de comprendre les raisons des différences dans la non réponse, surtout entre les groupes ethniques.

Marco de Referencia: El estado de Sikkim en la India presenta la proporción más alta de pacientes cuyo desenlace del tratamiento antituberculoso de primera línea se clasifica como 'fracaso' o 'cambiado a un esquema contra la tuberculosis multirresistente (TB-MDR)'.Objetivo: Evaluar los factores que se asocian con la falta de respuesta al tratamiento ('fracaso' o 'cambiado a un esquema contra la TB-MDR').Métodos: Se llevó a cabo un estudio de cohortes, a partir de los datos del Programa Revisado Nacional contra la Tuberculosis, de todos los pacientes registrados en el 2015 en tratamiento antituberculoso de primera línea. Además, se entrevistaron 42 pacientes (que no respondieron al tratamiento), con el fin de verificar su situación actual.Resultados: De los 1508 pacientes inscritos para tratamiento, cerca del 9% se clasificaron sin respuesta al tratamiento. Los factores del paciente que se asociaron con la falta de respuesta fueron los siguientes: un entorno urbano (OR ajustado [ORa] 2,39; IC95% 1,22­4,67), la etnia (pertenencia a grupos tribales, ORa 1,73; IC95% 1,17­2,57 u otras poblaciones indias ORa 1,83; IC95% 1,29­2,60 cuando se compararon con los pacientes de origen nepalés) y el retratamiento antituberculoso (ORa 2,40; IC95% 1,99­2,91). De los pacientes entrevistados, 28 habían recibido tratamiento por TB farmacorresistente (67%).Conclusión: En Sikkim, uno de cada 11 pacientes no respondió al tratamiento de primera línea contra la TB. Se precisarían estudios genéticos de la interacción entre el hospedero y el patógeno y estudios sociales conductuales que permitan comprender las razones de las diferencias en la falta de respuesta, sobre todo entre los diferentes grupos étnicos.

Dotting the Three I's for collaborative TB-HIV activities: evaluation of a pilot programme in Kathmandu, Nepal.

Setting: The three government tertiary care hospitals providing care for people living with the human immunodeficiency virus (PLHIV) in Kathmandu, Nepal. Objectives: To assess 1) the screening cascades for intensified case finding for tuberculosis (TB), 2) isoniazid preventive therapy (IPT), including demographic and clinical factors associated with treatment interruption, and 3) TB infection control (IC) in the health facilities. Design: A cross-sectional study of new PLHIV enrolled from January 2012 to December 2014. Results: Among 572 registered PLHIV, 91% were on antiretroviral therapy. Of those registered, 561 (98%) were screened for TB and 73 (13%) were diagnosed with TB (17 [25%] sputum smear-positive, 17 [25%] smear-negative and 35 [51%] extra-pulmonary). Among the 488 (87%) PLHIV without active TB, 157 (32%) were initiated on IPT, of whom 136 (87%) completed treatment and 17 (11%) interrupted treatment. Those who experienced adverse events were 12 times more likely to interrupt IPT. TB IC showed gaps in personal control measures and supporting structures and policies. Conclusion: The implementation of the Three I's for collaborative TB-HIV activities in pilot sites in Nepal was successful and should be scaled up.

Contexte : Les trois hôpitaux d'état de niveau tertiaire offrant des soins aux personnes vivant avec le virus de l'immunodéficience humaine (PVVIH) à Katmandou, Népal.Objectifs : Evaluer 1) les étapes du dépistage pour une recherche intensifiée de cas (ICF) de tuberculose (TB) ; 2) le traitement préventif par isoniazide (TPI), y compris les facteurs démographiques et cliniques associés à l'interruption du traitement ; et 3) la lutte contre l'infection tuberculeuse (IC) dans les structures de santé.Schéma : Etude transversale auprès des nouveaux PVVIH enrôlés entre janvier 2012 et décembre 2014.Résultats : Parmi 572 PVVIH enregistrés, 91% étaient sous traitement antirétroviral. Parmi les inscrits, 561 (98%) ont eu un dépistage de TB et 73 (13%) ont eu un diagnostic de TB (17 [25%] TB à frottis positif, 17 [25%] TB à frottis négatif et 35 [51%] TB extra-pulmonaire). Parmi les 488 (87%) PVVIH sans TB active, 157 (32%) ont été mis sous TPI, 136 (87%) d'entre eux l'ont achevé et 17 (11%) ont interrompu le traitement. Ceux qui ont eu des effets secondaires ont été 12 fois plus susceptibles d'interrompre le TPI. Les mesures de lutte contre l'infection TB connaissent des lacunes en termes de mesures de protection individuelle et des structures et des politiques de soutien.Conclusion : La mise en œuvre des Trois I pour des activités collaborative TB-VIH dans des sites pilotes au Népal s'est faite avec succès et devrait être étendue.

Marco de referencia: Los tres hospitales públicos de atención terciaria que prestan servicios a las personas aquejadas de infección por el virus de la inmunodeficiencia humana (PVVIH) en Katmandú, Nepal.Objetivos: Evaluar 1) el algoritmo de detección en la búsqueda intensiva de casos de tuberculosis (TB); 2) el tratamiento preventivo con isoniazida (TPI), incluidos los factores demográficos y clínicos que se asocian con su interrupción; y 3) el control de la infección (IC) tuberculosa en los establecimientos de salud.Método: Fue este un estudio transversal de los PVVIH recién inscritos en el programa de enero del 2012 a diciembre del 2014.Resultados: De 572 PVVIH inscritos, el 91% recibía tratamiento antirretrovírico. De los pacientes registrados, en 561 se practicó la detección sistemática de la TB (98%) y se diagnosticaron 73 casos de enfermedad activa (13%) (17 obtuvieron un resultado positivo de la baciloscopia del esputo [25%], 17 un resultado negativo [25%] y ocurrieron 35 casos de TB extrapulmonar [51%]). De los 488 PVVIH sin TB activa (87%), 157 iniciaron el TPI (32%), 136 de ellos lo completaron (87%) y 17 lo interrumpieron (11%). La probabilidad de interrumpir el TPI fue 12 veces mayor en los pacientes que presentaron reacciones adversas. Al evaluar las medidas de control de las infecciones se observaron deficiencias en las medidas personales, las estructuras auxiliares y en las normas.Conclusión: La ejecución de actividades conjuntas, los Tres I's, de atención de la TB-VIH en tres centros piloto en Nepal fue eficaz y sería muy útil ampliar su escala de aplicación.

Job satisfaction of overseas-qualified nurses working in Australian hospitals.

AIMS: The aims of this study were to explore factors associated with the job satisfaction of overseas-qualified nurses working in public hospitals in South Australia and to compare whether factors associated with job satisfaction of overseas nurses from English-speaking backgrounds differed from those from non-English-speaking backgrounds. BACKGROUND: Overseas-qualified nurses have become an essential part of the nursing workforce in Australia. Although this nurse population has different expectations and values in relation to their jobs when compared with local nurses, studies on job satisfaction among overseas nurses are scarce. METHODS: A cross-sectional survey using the Job Satisfaction of Overseas-Qualified Nurses questionnaire was conducted in five major public hospitals in South Australia. RESULTS: One hundred and fifty-one overseas-qualified nurses completed the questionnaire. Four factors were found to influence job satisfaction: Supportive work environment, interpersonal relationships, communication in English, and salary and salary-related benefits. Communication in English was the predominant factor that was associated with job satisfaction in nurses from non-English-speaking backgrounds. This group of nurses also showed a negative correlation between length of stay in Australia and satisfaction with their work environment. Participants' responses to open-ended questions revealed issues relating to discrimination and racism. CONCLUSION: Supportive work environment, interpersonal relationships, communication in English, and salary and salary-related benefits were major factors associated with job satisfaction in overseas-qualified nurses in this study. Nurses from non-English-speaking backgrounds faced additional challenges in communication in the workplace and in dealing with issues of discrimination and racism. IMPLICATIONS FOR NURSING AND/OR HEALTH POLICY: Nurses from non-English-speaking backgrounds need to be supported early in their employment, especially with their communication skills. Consideration also needs to be given to the education of local staff regarding cultural differences of overseas workers.

Surgical safety distances in the infratemporal fossa: three-dimensional measurement study.

The wedge-shaped infratemporal fossa is a constricted space and has long been a surgical challenge, mainly due to difficulties in access. Three-dimensional (3D) reconstruction of the skull, internal carotid artery (ICA), and internal jugular vein (IJV) was carried out using enhanced computed tomography (CT) data, to measure the safety distances in relation to infratemporal fossa surgery. Fifty enhanced CT datasets were selected to reconstruct 3D images by segmentation technique. The anatomical routes of the ICA, IJV, and the styloid process (SP) were observed. The following were measured: SP length, height of the pterygoid plates (PP height), distances from the pterygoid process (antero-inferior and anterosuperior border) to the leading edge of the ICA (PP-ICA (inferior), PP-ICA (superior)), and distance between the most prominent point of the zygomatic arch and the medial pterygoid plate (Zyg-MPP). The mean measurements of SP length, PP height, and the distances PP-ICA (inferior), PP-ICA (superior), and Zyg-MPP were 30.64 mm, 26.61 mm, 31.16 mm, 34.37 mm, and 51.37 mm, respectively. No significant differences were observed by age group, except the distance of PP-ICA (inferior) on the left side. In centres without intraoperative navigation facilities, proper knowledge of the anatomy, particularly of bony landmarks and the safe distances to nearby neurovascular structures, can provide useful information to ensure safe operations.

Distribution and skill mix of health workforce in Nepal.

BACKGROUND: Distribution and skill mix of health workforce has always been a challenge in rural Nepal. Workforce surpluses or shortages and inappropriate skill mix, decrease productivity and efficiency, deplete scarce resources and squander worker capabilities. This study was aimed at generating evidences on the current distribution and skill mix of health workforce in Nepal. METHODS: A cross-sectional study was conducted using both qualitative and quantitative methods.Fifteen districts representing three eco-developmental regions of Nepal were selected using multi-stage cluster sampling method. Out of 404 sampled health institutions, 747 health workers from 375 health institutions were interviewed. Observation was carried out in 256 health facilities. RESULTS: Currently, the vacant positions are mostly of doctors 74(38%) technicians 28 (21%) nurses 50 (10%) and paramedics 26 (6%)with respect to sanctioned positions. Variations of fulfilled positions occurred in all three ecological belts, with the Hill belt having the highest proportion of vacant posts 116 (16%).On the basis of types of health facilities, ayurvedic centres have the highest fulfilled positions 55 (95%) and the lowest in primary healthcare centres (PHCCs) 162 (81%). Proper skill mix was observed in 6 (43%) of hospitals and 3(18%) of PHCCs.Only 132 (17.7%) of health workers have taken part in orientation on non-communicable diseases (NCDs) despite the increasing trend of NCDs. CONCLUSIONS: There is scarcity of health workforce with appropriate skills, particularly in rural Nepal. Sanctioned positions and categories of health workers need to be revised on the basis of population growth and epidemiological shifts.

Hepatoprotective activity of the methanolic extract of Fagonia indica Burm in carbon tetra chloride induced hepatotoxicity in albino rats

Objective: To investigate hepatoprotective activity of the methanolic extract of Fagonia indica Burm. on CCl4 induced hepatotoxicity in albino rats. Methods: Animals in Group 1 served as vehicle control, Group 2 served as hepatotoxin (CCl4 2ml/kg, s.c) treated group, Group 3 served as standard (Silymarin 50mg/kg, p.o.) treated group. Group4 and 5 served as methanolic extract of Fagonia indica (MEFI) in different doses (200 mg/kg and 400 mg/kg b.w., p.o).The degree of protection was determined by measuring levels of biochemical marker like SGOT, SGPT, ALP, Bilirubin (Total & Direct) and Cholesterol. The histopathological studies also show the hepatic protection of the test extracts. Results: The levels of the biochemical parameters such as SGPT, SGOT, ALP, Total bilirubin, Direct bilirubin and Cholesterol were significantly increased in CCl4 treated rats when compared with the normal group (P<0.05), but the MEFI (400 mg/kg, bw) treated rats showed maximum reduction of SGOT (114.83±1.51), SGPT (164.33±1.25), ALP (154.83±1.53), Total bilirubin (1.55±0.01), Direct bilirubin (0.65±0.009) and Cholesterol (193.00±1.06) in a significant manner. Histopathological studies also reveal the hepatoprotection property of MEFI in a dose dependent manner. Conclusions: These results suggest that MEFI in different doses showed significant hepatoprotective activity against CCl4 induced hepatotoxicity and this might be due to the presence of flavonoids and tannins. Further research is sought to explore the exact mechanism of action and phytoconstituents responsible for the pharmacological response.

Synthesis, molecular modeling, and pharmacological testing of bis-quinolinium cyclophanes: potent, non-peptidic blockers of the apamin-sensitive Ca(2+)-activated K(+) channel.

The synthesis and pharmacological testing of two series of novel bis-quinolinium cyclophanes as blockers of the apamin-sensitive Ca(2+)-activated K(+) (SK(Ca)) channel are presented. In these cyclophanes the two 4-aminoquinolinium groups are joined at the ring N atoms (linker L) and at the exocyclic N atoms (linker A). In those cases where A and L contain two or more aromatic rings each, the activity of the compound is not critically dependent upon the nature of the linkers. When A and L each have only one benzene ring, the blocking potency changes dramatically with simple structural variations in the linkers. One of these smaller cyclophanes having A = benzene-1,4-diylbis(methylene) and L = benzene-1, 3-diylbis(methylene) (3j, 6,10-diaza-1,5(1,4)-diquinolina-3(1,3),8(1, 4)-dibenzenacyclodecaphanedium tritrifluoroacetate, UCL 1684) has an IC(50) of 3 nM and is the most potent non-peptidic SK(Ca) channel blocker described to date. Conformational analysis on the smaller cyclophanes using molecular modeling techniques suggests that the differences in the blocking potencies of the compounds may be attributable to their different conformational preferences.

Intravenous streptokinase in the management of a subset of patients with unstable angina: a randomized controlled trial.

We report the results of a randomized controlled trial of intravenous streptokinase in a subset of patients with unstable angina. Seventy-six patients were admitted with prolonged (more than 20 minutes) angina at rest of less than 3 weeks onset. Fifty-two patients continued to have more than 3 episodes of prolonged angina in 48 hours on medical therapy with metoprolol, isosorbide dinitrate, nifedipine and intravenous nitroglycerin. Forty-eight patients consented to enter the study and were randomized into two groups. The first group, of 24 patients, received 1.5 million units of streptokinase infusion and the second group, also of 24 patients, received a placebo. Pain relief within 48 hours was achieved in 19/24 (79.1%) patients after streptokinase infusion as compared to 9/24 (37.5%) of the controls (P less than 0.05). Approximately 90% (17/19) of patients responding to streptokinase therapy were relieved of chest pain within the first six hours as against none in the controls. The incidence of acute myocardial infarction within six months was 12.5% (3/24) in those receiving streptokinase and 25% (6/24) in the controls. Mortality at six months stood at 8.33% (2/24) in the treated patients and 16.6% (4/24) in the controls. Intravenous streptokinase thus appears to be of benefit in patients with angina at rest of recent onset which does not respond to conventional medical therapy.

Failure of oral atenolol and verapamil to increase the capacity and duration of exercise in patients in sinus rhythm with mitral stenosis.

The efficacy of oral atenolol in increasing the capacity and duration of exercise in 43 patients in sinus rhythm with mitral stenosis was evaluated and compared with that of oral verapamil in an open-label cross-over design. It was observed that although oral atenolol (100 mg per day) caused significant reductions in heart rate while resting and during exercise (P less than 0.001), the increases in capacity and duration of exercise were not significant. Oral verapamil (80 mg three times per day) also caused significant reductions in the heart rates at rest and during exercise (P less than 0.05) but the increases observed, although greater than that with atenolol, failed to reach the level of statistical significance. Occasional side effects occurred with both the drugs. Subjective symptoms of dyspnoea at rest and on exertion were relieved with both the drugs. We conclude that, although both drugs reduce the symptoms of dyspnoea, they cause only minor increases in the objective parameters. They do not, therefore, provide an alternative to surgery and have only a temporary place in the management of patients in sinus rhythm with mitral stenosis who are awaiting surgery.

Development of subaortic stenosis and regurgitation several years after successful operation on a common atrium.

A patient who had had successful operation for a common atrium subsequently developed subaortic stenosis and regurgitation several years later. The diagnosis of subaortic lesion was confirmed by echocardiography. This case shows that the left ventricular outflow tract gradient should be measured before operation for common atrium and that after operation such cases should be examined by cross sectional echocardiography at follow up visits.

Value of the treadmill exercise test in asymptomatic and minimally symptomatic patients with chronic severe aortic regurgitation.

The value of the graded treadmill exercise test was assessed in 19 asymptomatic and minimally symptomatic (13 NYHA class I and 6 NYHA class II) male patients with chronic severe aortic regurgitation. It was observed that, in 2 patients who showed significant ST segment depression at peak exercise, the total exercise duration was significantly shorter (P less than 0.001) than in the patients not showing such changes. During left ventricular and aortic root angiography (in both patients) and selective left coronary angiography (in one of them), ST segment changes similar to those seen during exercise testing were observed. The mean rise in left ventricular end-diastolic pressure after injection of contrast material was significantly more (P less than 0.001) in these 2 patients compared to the other 17 patients. Both patients had normal resting M-mode echocardiographic parameters. It is concluded that ST segment depression on exercise testing and reduced exercise capacity are indicants of exercise-induced left ventricular dysfunction in asymptomatic and minimally symptomatic patients with chronic severe aortic regurgitation. Furthermore, it is suggested that this simple and cheap test can be used for serial evaluation of such patients in the absence of the facility of radionuclide cineangiography.

Sinus arrest caused by atenolol-verapamil combination.

A case on concomitant atenolol-verapamil therapy for hypertension and angina pectoris, developing sinus arrest and life-threatening bradycardia is described. The complication occurred with low doses of both the agents and normal electrophysiologic status of the heart. The example suggests that pharmacodynamic synergism contributes more than pharmacokinetic interaction causing adverse reactions during beta blocker-verapamil therapy.