Outcomes of decentralizing hypertension care from district hospitals to health centers in Rwanda, 2013-2014.

SETTING: Three district hospitals (DHs) and seven health centers (HCs) in rural Rwanda. OBJECTIVE: To describe follow-up and treatment outcomes in stage 1 and 2 hypertension patients receiving care at HCs closer to home in comparison to patients receiving care at DHs further from home. DESIGN: A retrospective descriptive cohort study using routinely collected data involving adult patients aged ⩾18 years in care at chronic non-communicable disease clinics and receiving treatment for hypertension at DH and HC between 1 January 2013 and 30 June 2014. RESULTS: Of 162 patients included in the analysis, 36.4% were from HCs. Patients at DHs travelled significantly further to receive care (10.4 km vs. 2.9 km for HCs, P < 0.01). Odds of being retained were significantly lower among DH patients when not adjusting for distance (OR 0.11, P = 0.01). The retention effect was consistent but no longer significant when adjusting for distance (OR 0.18, P = 0.10). For those retained, there was no significant difference in achieving blood pressure targets between the DHs and HCs. CONCLUSION: By removing the distance barrier, decentralizing hypertension management to HCs may improve long-term patient retention and could provide similar hypertension outcomes as DHs.

Advances in malaria elimination in Botswana: a dramatic shift to parasitological diagnosis, 2008-2014.

Background: Malaria elimination requires infection detection using quality assured diagnostics and appropriate treatment regimens. Although Botswana is moving towards malaria elimination, reports of unconfirmed cases may jeopardise this effort. This study aimed to determine the proportion of cases treated for malaria that were confirmed by rapid diagnostic testing (RDT) and/or microscopy. Methods: This was a retrospective descriptive study using routine national data from the integrated disease surveillance and case-based surveillance systems from 2008 to 2014. The data were categorised into clinical and confirmed cases each year. An analysis of the data on cases registered in three districts that reported approximately 70% of all malaria cases was performed, stratified by year, type of reporting health facilities and diagnostic method. Results: During 2008-2014, 50 487 cases of malaria were reported in Botswana, and the proportion of RDT and/or blood microscopy confirmed cases improved from 6% in 2008 to 89% in 2013. The total number of malaria cases decreased by 97% in the same period, then increased by 41% in 2013. Conclusion: This study shows that malaria diagnostic tests dramatically improved malaria diagnosis and consequently reduced the malaria burden in Botswana. The study identified a need to build capacity on microscopy for species identification, parasite quantification and guiding treatment choices.

Contexte : L'élimination du paludisme requiert la détection des infections grâce à des diagnostics de qualité garantie et à des traitements appropriés. Le Botswana évolue vers l'élimination du paludisme, mais des déclarations de cas non confirmés pourraient compromettre cet effort. Cette étude a visé à déterminer la proportion de cas traités pour paludisme et confirmés par des tests de diagnostic rapide (RDT) et/ou microscopie.Méthodes : Etude rétrospective descriptive qui a utilisé les données nationales de routine des systèmes de surveillance intégrée des maladies et de surveillance basée sur les cas de 2008 à 2014. Les données ont été classées en cas cliniques et confirmés chaque année. Une analyse des données des cas enregistrés dans trois districts déclarant environ 70% des cas de paludisme a été réalisée et stratifiée par année, par type de structure de santé et par méthode de diagnostic.Résultats : En 2008­2014, il y a eu 50 487 cas de paludisme déclarés au Botswana et les cas confirmés par RDT et/ou la microscopie se sont améliorés de 6% en 2008 à 89% en 2013. De plus, le nombre total de cas a chuté de 97% dans la même période, puis est remonté de 41% en 2013.Conclusion : Cette étude a montré que l'utilisation des tests de diagnostic du paludisme avaient considérablement amélioré le diagnostic et avaient par conséquent réduit le fardeau du paludisme au Botswana. L'étude a identifié un besoin de renforcement des capacités en matière de microscopie pour l'identification des espèces et la quantification des parasites et pour guider le choix des traitements.

Marco de referencia: La eliminación del paludismo exige detectar el parasitismo con medios diagnósticos de calidad garantizada y administrar esquemas terapéuticos apropiados. Botswana avanza hacia la eliminación del paludismo, pero los informes de casos no confirmados pueden poner en peligro este esfuerzo. En el presente estudio se determinó la proporción de casos tratados por paludismo, con confirmación diagnóstica mediante pruebas de diagnóstico rápido, examen microscópico o ambos.Métodos: Un estudio retrospectivo descriptivo a partir de los datos corrientes de ámbito nacional de los Sistemas de Vigilancia Integrada de Enfermedades y de Vigilancia Basada en los Casos, del 2008 al 2014. Los datos se categorizaron en casos clínicos y casos confirmados cada año. Se realizó un análisis de datos de los casos registrados en tres distritos que notifican alrededor del 70% de los casos de paludismo, estratificados por año, tipo de establecimiento de salud que notificaba y método diagnóstico.Resultados: Del 2008 al 2014 se notificaron 50 487 casos de paludismo en Botswana y la proporción de casos confirmados mediante pruebas rápidas o examen microscópico de muestras sanguíneas aumentó del 6% en el 2008 al 89% en el 2013. Además, el número total de casos disminuyó un 97% durante el mismo período y luego aumentó de nuevo un 41% en el 2013.Conclusión: El presente estudio puso de manifiesto que las pruebas diagnósticas del paludismo mejoraron de manera notable el diagnóstico y con ello disminuyeron la carga de morbilidad por paludismo en Botswana. El estudio reveló la necesidad de fortalecer la capacidad en materia de microscopia con el fin identificar la especie, cuantificar los parásitos y orientar las opciones terapéuticas.

Did microbial larviciding contribute to a reduction in malaria cases in eastern Botswana in 2012-2013?

Setting: Larviciding has potential as a component of integrated vector management for the reduction of malaria transmission in Botswana by complementing long-lasting insecticide nets and indoor residual sprays. Objective: To evaluate the susceptibility of local Anopheles to commonly used larvicides. Design: This field test of the efficacy of Bacillus thuringiensis subsp. israliensis vs. Anopheles was performed by measuring larval density before treatment and 24 h and 48 h after treatment in seven sites of Bobirwa district, eastern Botswana, in 2012 and 2013. Vector density and malaria cases were compared between Bobirwa and Ngami (northwestern Botswana), with no larviciding in the control arm. Results: Larviciding reduced larval density by 95% in Bobirwa in 2012, with two cases of malaria, while in 2013 larval density reduction was 81%, with 11 cases. Adult mosquito density was zero for both years in Robelela village (Bobirwa), compared to respectively four and 26 adult mosquitoes per room in Shorobe village (Ngami) in 2012 and 2013. There were no cases of malaria in Robelela in either year, but in Shorobe there were 20 and 70 cases, respectively, in 2012 and 2013. Conclusion: Larviciding can reduce the larval density of mosquitoes and reduce malaria transmission in Botswana. Large-scale, targeted implementation of larviciding in districts at high risk for malaria is recommended.

Contexte : Les opérations larvicides ont, en tant qu'élément de la gestion intégrée des vecteurs, le potentiel de réduire la transmission du paludisme au Botswana en complétant les moustiquaires imprégnées d'insecticide rémanent et la pulvérisation d'insecticide a effet rémanent. Objectif : Evaluer la sensibilité des Anophèles locaux aux larvicides généralement utilisés.Schéma : Le test de terrain de l'efficacité du Bacillus thuringiensis sous-espèce israeliensis a été réalisé vis-à-vis d'Anopheles en mesurant la densité larvaire avant traitement et 24 h et 48 h après traitement dans sept sites du district de Bobirwa (est du Botswana) en 2012 et 2013. La densité vectorielle et les cas de paludisme ont été comparés à Bobirwa et à Ngami (nord-ouest du Botswana), le district témoin sans opérations larvicides.Résultats : Les opérations larvicides ont réduit la densité larvaire de 95%, avec deux cas en 2012, tandis qu'en 2013 la réduction de la densité larvaire a été de 81%, avec 11 cas à Bobirwa. La densité de moustiques adultes a été de zéro pour les deux années dans le village de Robelela (Bobirwa), comparé à quatre et à 26 adultes par pièce dans le village de Shorobe (Ngami) en 2012 et 2013, respectivement. Il n'y a pas eu de cas de paludisme à Robelela au cours des deux années, mais respectivement 20 et 70 cas sont survenus à Shorobe en 2012 et 2013.Conclusion: Les opérations larvicides peuvent réduire la densité larvaire des moustiques et réduire la transmission du paludisme au Botswana. La mise en œuvre à grande échelle et ciblée d'opérations larvicides dans les districts à haut risque de paludisme est recommandée.

Marco de referencia: La aplicación de larvicidas podría convertirse en un componente del plan integrado de control de los vectores destinado a disminuir la transmisión del paludismo en Botswana, que complemente la utilización de mosquiteros impregnados de insecticidas de larga duración y la fumigación de interiores con insecticidas de acción residual.Objetivo: Evaluar la susceptibilidad de los anófeles locales a los larvicidas más utilizados.Método: Se llevó a cabo un ensayo sobre el terreno de la eficacia de Bacillus thuringiensis subespecie israliensis contra el género Anopheles, mediante la medición de la densidad larvaria antes del tratamiento y 24 h y 48 h después del mismo, en siete lugares del distrito de Bobirwa (Botswana oriental) en el 2012 y el 2013. Se compararon la densidad del vector y los casos de paludismo en Bobirwa y en Ngami (Botswana nororiental), que constituyó la rama testigo del estudio sin tratamiento larvicida.Resultados: La aplicación del larvicida en Bobirwa disminuyó un 95% la densidad larvaria y se presentaron dos casos de paludismo en el 2012, pero en el 2013 esta disminución fue del 81% y se presentaron 11 casos. La densidad de mosquitos adultos fue cero en ambos años en la localidad de Robelela (Bobirwa), en comparación con cuatro a 26 adultos por pieza en Shorobe (Ngami) en el 2012 y el 2013, respectivamente. No se presentaron casos de paludismo en Robelela en estos dos años, pero en Shorobe ocurrieron 20 casos en el 2012 y 70 en el 2013.Conclusión: La aplicación de larvicidas puede disminuir la densidad de mosquitos y la transmisión del paludismo en Botswana. Se recomienda una aplicación de larvicida dirigida en gran escala en los distritos con alto riesgo de transmisión de paludismo.

Closing the gap: decentralising mental health care to primary care centres in one rural district of Rwanda.

Setting: Programmes that integrate mental health care into primary care settings could reduce the global burden of mental disorders by increasing treatment availability in resource-limited settings, including Rwanda. Objective: We describe patient demographics, service use and retention of patients in care at health centres (HC) participating in an innovative primary care integration programme, compared to patients using existing district hospital-based specialised out-patient care. Design: This was a retrospective cohort study using routinely collected data from six health centres and one district hospital from October 2014 to March 2015. Results: Of 709 patients, 607 were cared for at HCs; HCs accounted for 88% of the total visits for mental disorders. Patients with psychosis used HC services more frequently, while patients with affective disorders were seen more frequently at the district hospital. Of the 68% of patients who returned to care within 90 days of their first visit, 76% had a third visit within a further 90 days. There were no significant differences in follow-up rates between clinical settings. Conclusion: This study suggests that a programme of mentorship for primary care nurses can facilitate the decentralisation of out-patient mental health care from specialised district hospital mental health services to HCs in rural Rwanda.

Contexte : Les programmes qui intègrent les soins de santé mentale dans les structures de soins de santé primaires pourraient réduire le fardeau mondial des troubles mentaux en augmentant la disponibilité du traitement dans des contextes de ressources limitées, notamment au Rwanda.Objectif : Nous décrivons les caractéristiques démographiques des patients, leur utilisation des services et la rétention des patients en traitement dans les centres de santé (HC) participant à un programme innovant d'intégration dans les soins de santé primaires, comparés aux patients recourant aux consultations spécialisées existantes, basées dans les hôpitaux de district.Schéma : Une étude rétrospective de cohorte basée sur des données recueillies en routine dans six centres de santé et dans un hôpital de district, entre octobre 2014 et mars 2015.Résultats : De 709 patients, 607 ont été soignés dans les HC et les HC ont totalisé 88% de l'ensemble des consultations pour troubles mentaux. Les patients atteints de psychose ont plus souvent utilisé les services des HC, tandis que les patients atteints de troubles affectifs ont été plus souvent vus à l'hôpital de district. De 68% des patients qui sont revenus dans les 90 jours suivant leur première consultation, 76% ont eu une troisième consultation au cours des 90 jours suivants. Il n'y a pas eu de différences significatives en termes de taux de suivi entre les deux contextes cliniques.Conclusion : Cette étude suggère qu'un programme de tutorat destiné aux infirmiers de soins de santé primaires peut faciliter la décentralisation de la prise en charge de la santé mentale en consultation externe des services de santé mentale des hôpitaux spécialisés de district vers les HC dans le Rwanda rural.

Marco de referencia: Los programas que integran la atención de la salud mental al entorno de la atención primaria podrían reducir la carga mundial de morbilidad por trastornos mentales, al aumentar la disponibilidad del tratamiento en los medios con escasos recursos, por ejemplo en Rwanda.Objetivo: Se describen las características demográficas, la utilización de los servicios y la retención en la atención, de los pacientes atendidos en los centros de salud que participan en un programa innovador de atención primaria y se comparan con los pacientes que acuden a la consulta ambulatoria especializada que se presta en un hospital distrital.Método: Fue este un estudio de cohortes retrospectivo a partir de los datos recogidos de manera sistemática en seis centros de salud y un hospital distrital, de octubre del 2014 a marzo del 2015.Resultados: De los 709 pacientes, se atendieron 607 en los centros de salud y estos centros realizaron el 88% del total de consultas por trastornos mentales. Los pacientes con trastornos psicóticos utilizaban con mayor frecuencia los servicios en los centros de salud, pero los pacientes con trastornos del afecto se atendían con mayor frecuencia en el hospital distrital. El 68% de los pacientes regresaron al servicio de atención en los 90 días que siguieron a su primera consulta y el 76% de ellos acudió a una tercera consulta en los siguientes 90 días. No se observaron diferencias significativas en las tasas de seguimiento en los diferentes entornos clínicos.Conclusión: Los resultados del presente estudio ponen de manifiesto que un programa tutorial dirigido al personal de enfermería de los centros de atención primaria puede facilitar la descentralización de la atención ambulatoria de los pacientes con trastornos de salud mental, desde el hospital distrital con servicios especializados hacia los centros de salud en zonas rurales de Rwanda.

Did the 2014 Ebola outbreak in Liberia affect HIV testing, linkage to care and ART initiation?

Setting: Health facilities providing human immunodeficiency virus (HIV) testing, care and treatment in Liberia. Objective: To evaluate individuals aged ⩾15 years who were tested, diagnosed and enrolled into HIV care before (2013), during (2014) and after the Ebola outbreak (2015). Design: A cross-sectional descriptive study. Results: A median of 6930 individuals aged ⩾15 years per county were tested for HIV before the Ebola outbreak; this number declined by 35% (2444/6930) during the outbreak. HIV positivity remained similar before (7028/207 314, 3.4%) and during the outbreak (4146/121 592, 3.5%). During Ebola, HIV testing declined more in highly affected counties (68 035/127 468, 47%) than in counties that were less affected (16 444/23 955, 31%, P < 0.001). Compared to the pre-Ebola period, HIV testing in less-affected counties recovered more quickly during the post-outbreak period, with a 19% increase in testing, while medium and highly affected counties remained at respectively 38% and 48% below pre-outbreak levels. Enrolment for HIV care increased during and after the outbreak compared to the pre-Ebola period. Conclusion: HIV testing and diagnosis were significantly limited during the Ebola outbreak, with the most severe effects occurring in highly affected counties. However, enrolment for HIV care and treatment were resilient throughout the outbreak. Pro-active measures are needed to sustain HIV testing rates in future epidemics.

Contexte : Structures de santé offrant des tests et une prise en charge de l'infection par le virus de l'immunodéficience humaine (VIH) au Liberia.Objectif : Evaluer les personnes âgées de ⩾15 ans qui sont testées, diagnostiquées et enrôlées dans la prise en charge du VIH avant (2013), pendant (2014) et après la flambée d'Ebola (2015).Schéma : Étude descriptive transversale.Résultats : Une médiane de 6930 personnes âgées de ⩾15 ans par comté ont eu un test VIH avant la flambée d' Ebola ; ce nombre a décliné de 35% (2444/6930) pendant la flambée. La positivité du VIH est restée similaire avant (7028/207 314 ; 3,4%) et pendant la flambée d'Ebola (4146/121 592 ; 3,5%). Pendant Ebola, les tests VIH ont diminué davantage dans les comtés les plus affectés (68 035/127 468 ; 47%) comparés aux comtés moins affectés (16 444/23 955 ; 31% ; P < 0,001). Comparés à la période pré Ebola, les tests VIH dans les comtés les moins affectés ont récupéré plus rapidement pendant la période post flambée, avec une augmentation de 19% des tests, tandis que les comtés moyennement ou très affectés sont restés à 38% et à 48%, respectivement, sous les niveaux d'avant la flambée. L'enrôlement dans la prise en charge du VIH a augmenté pendant et après la flambée par rapport à la période pré Ebola.Conclusion : Le test et le diagnostic du VIH ont été significativement limités pendant la flambée d'Ebola, avec l'impact le plus grave dans les comtés les plus affectés. L'enrôlement dans la prise en charge du VIH a toutefois été résilient tout au long de la flambée. Des mesures proactives sont requises pour maintenir le taux des tests VIH lors de futures épidémies.

Marco de referencia: Los establecimientos de salud que prestan servicios de diagnóstico, atención y tratamiento de la infección por el virus de la inmunodeficiencia humana (VIH) en Liberia.Objetivo: Evaluar el número de personas de edad de ⩾15 años en quienes se practicó la prueba del VIH, se estableció el diagnóstico de infección por el virus y se inscribieron en el servicio de atención antes la epidemia de fiebre hemorrágica del Ébola (2013), durante el brote (2014) y después del mismo (2015).Método: Fue este un estudio transversal descriptivo.Resultados: La mediana del número de personas de edad de ⩾15 años en quienes se practicó la prueba del VIH antes del brote del Ébola por condado fue 6930; esta cifra disminuyó un 35% (2444/6930) durante el brote. La proporción de resultados positivos de la prueba permaneció estable antes del brote epidémico (7028/207 314 ; 3,4%) y durante el mismo (4146/121 592 ; 3,5%). Durante la epidemia del Ébola, la práctica de la prueba del VIH disminuyó más en los condados más afectados (68 035/127 468; −47%) que en los condados con una epidemia de menor nivel (16 444/23 955; −31%; P < 0,001). En comparación con el período pre-Ébola, la recuperación de la práctica de la prueba del VIH después de la epidemia en los condados menos afectados fue más rápida, con un aumento del 19%, pero en los condados donde la epidemia alcanzó un nivel intermedio o alto, las cifras permanecieron un 38% y un 48% inferiores al período pre-Ébola, respectivamente. La inscripción al programa de atención de la infección por el VIH aumentó durante el brote y después del mismo, en comparación con el período pre-Ébola.Conclusión: Los resultados del presente estudio revelan que las pruebas y el diagnóstico de la infección por el VIH se redujeron de manera notable durante el brote epidémico del Ébola y los efectos fueron más acentuados en los condados donde la epidemia alcanzó un alto nivel. Sin embargo, la inscripción al programa de atención y tratamiento resistió durante toda la epidemia. Se precisan medidas anticipatorias que favorezcan la estabilidad de la práctica de la prueba diagnóstica del VIH durante las epidemias futuras.

Did the Ebola outbreak disrupt immunisation services? A case study from Liberia.

Setting: All health facilities providing routine immunisation services in Liberia. Objective: To compare the number of routine facility-based and outreach immunisations and measles cases before, during and after the Ebola outbreak. Design: A descriptive cross-sectional study. Results: Immunisation coverage for fully immunised children before the Ebola outbreak was 73%. Immunisation coverage for all antigens declined by half compared to baseline during the outbreak. These findings were similar in facility-based and outreach immunisations. During the outbreak, the proportion of fully immunised children dropped by respectively 58%, 33% and 39% in the most, moderately and least Ebola-affected counties. Immunisation rate of recovery in the post-Ebola period was respectively 82%, 21% and 9% in the most, moderately and least affected counties compared to the Ebola-outbreak period. Outreach immunisation recovered slowly compared to facility-based immunisation. The mean number of measles cases reported per month was 12 pre-Ebola, 16 Ebola and 60 post-Ebola. Conclusion: This study provides insights into the possible impact of an Ebola outbreak on countrywide immunisation. The outbreak weakened a struggling national immunisation programme, and post-outbreak recovery took significant time, which likely contributed to the measles epidemic. Recommendations for the improvement of immunisation services that could limit further preventable epidemics in Liberia and similar contexts at risk for Ebola are provided.

Contexte : Toutes les structures de santé offrant des services de vaccination de routine au Liberia.Objectif : Comparer le nombre de vaccinations de routine dans des structures de santé et en stratégies avancées et le nombre de cas de rougeole avant, pendant et après l'épidémie d'Ebola.Schéma : Étude descriptive transversale.Résultats : La couverture vaccinale des enfants complètement immunisés avant l'épidémie d'Ebola était de 73%. La couverture vaccinale pour tous les antigènes a décliné de moitié pendant la flambée comparée à la période précédente. Ces résultats ont été similaires pour les vaccinations dans les structures de santé et les vaccinations périphériques. Pendant la flambée, la proportion d'enfants complètement immunisés a chuté de 58%, 33% et 39%, respectivement, dans les contés gravement, moyennement et faiblement affectés par Ebola. Le taux de vaccination de récupération dans la période post Ebola a été de 82%, 21% et 9%, respectivement, dans les comtés gravement, moyennement et faiblement affectés par Ebola comparés à la période de la flambée d'Ebola. Les vaccinations dans la communauté ont récupéré plus lentement que les vaccinations en structures de santé. Le nombre moyen mensuel de cas de rougeole rapporté a été de 12 avant Ebola, 16 Ebola et 60 après Ebola.Conclusion : Cette étude permet de mieux comprendre l'impact possible d'une épidémie d'Ebola sur le programme de vaccination dans le pays. La flambée a affaibli un programme national de vaccination déjà en difficulté et après la flambée la récupération a pris du temps, ce qui a sans doute contribué à l'épidémie de rougeole. Des recommandations pour une amélioration des services de vaccination qui pourraient limiter les épidémies évitables à l'avenir au Liberia et dans des contextes similaires à risque d'Ebola sont proposées.

Marco de referencia: Todos los establecimientos de salud que prestan servicios corrientes de vacunación en Liberia.Objetivo: Comparar el número de vacunaciones corrientes institucionales y extrainstitucionales practicadas y de casos de sarampión antes de la epidemia de fiebre hemorrágica del Ébola, durante el brote y después del mismo.Método: Fue este un estudio transversal descriptivo.Resultados: La cobertura de los niños con un esquema completo de vacunación antes de la epidemia del Ébola era 73%. La cobertura con todos los antígenos disminuyó un 50% durante el brote epidémico en comparación con los datos preepidémicos. Esta proporción fue equivalente en la vacunación institucional y periférica. Durante el brote, la proporción de niños con un esquema completo de vacunación disminuyó según la intensidad alta, moderada o baja de la epidemia en un 58%, un 33% y un 39%, respectivamente. La tasa correspondiente de recuperación de la vacunación después del período epidémico fue de 82%, 21% y 9% con respecto al período epidémico. La vacunación periférica se recuperó más lentamente que la vacunación practicada en los establecimientos de salud. El promedio mensual de casos de sarampión notificados fue 12 antes del brote del Ébola, 16 durante la epidemia y 60 después de la misma.Conclusión: Los resultados del presente estudio enriquecen la percepción de las repercusiones que puede provocar una epidemia de fiebre hemorrágica del Ébola en el sistema de vacunación a escala del país. El brote epidémico debilitó aun más el programa nacional de vacunación y su recuperación precisó un tiempo considerable; es probable que este factor haya contribuido al surgimiento de la epidemia de sarampión. Se aportan recomendaciones encaminadas a mejorar los servicios de vacunación, que pueden limitar mejor las epidemias prevenibles en Liberia y en otros entornos comparables donde existe un riesgo de aparición de la fiebre del Ébola.

The burden of road traffic injuries in an emergency department in Addis Ababa, Ethiopia.

SETTING: The emergency department (ED) of Zewditu Memorial Hospital, Addis Ababa, Ethiopia. OBJECTIVE: To document the proportion, trend, characteristics and outcomes of road traffic injury (RTI) related ED admissions (⩾15 years) between 2014 and 2015. DESIGN: A retrospective, cross-sectional study using routinely collected ED data. RESULTS: Of 10 007 ED admissions, 779 (8%) were RTI cases; this proportion peaked in the month of January (11%). Medical records were available for 522 (67%) of these RTI cases. The median age was 28 years and 69% were males. The majority were pedestrians (69%) injured by an automobile (78%). On triage, 32% were classified as needing urgent/immediate intervention. Head injuries (20%) were the second most common injury after lower limb injuries (36%). ED outcomes were as follows: discharged (68%), hospitalised (17%), referred (17%) and died (1%). Among the 78 hospitalised cases, respectively 62% and 16% were admitted to the surgical and orthopaedic departments. Of 146 RTI cases with head injuries, 25% were hospitalised, of whom 82% were admitted to the surgical department. CONCLUSION: Our findings can guide policy makers in referral hospitals in improving the planning of hospital resources and the prioritisation of public health needs linked to further urban development. A comprehensive plan to prevent RTIs, particularly among pedestrians in Addis Ababa, is urgently needed.

Contexte : Le service des urgences de l'hôpital Zewditu Memorial, Addis-Abeba, Ethiopie.Objectif : Documenter la proportion, la tendance, les caractéristiques et le devenir des patients (âgés ⩾15 ans) admis pour des blessures de la route (RTI) entre 2014 et 2015.Schéma : Une étude rétrospective transversale basée sur des données recueillies en routine par le service des urgences.Résultats : Sur 10 007 admissions aux urgences, 779 (8%) étaient des cas de RTI; cette proportion culminait au mois de janvier (11%). Les dossiers médicaux ont été disponibles pour 522 (67%) de ces cas de RTI. Leur âge médian était de 28 ans et 69% étaient des hommes. La majorité était des piétons (69%) blessés par une automobile (78%). Lors du triage, 32% ont été classés comme ayant besoin d'une intervention urgente/immédiate. Les traumatismes crâniens (20%) étaient au deuxième rang, suivant les blessures des membres inférieurs (36%). Le devenir des patients a été le suivant : sortie (68%), hospitalisation (17%), référence (17%) et décès (1%). Parmi les 78 cas hospitalisés, respectivement 62% et 16% ont été admis dans les services de chirurgie et d'orthopédie. Sur les 146 cas de RTI ayant eu un traumatisme crânien, 25% ont été hospitalisés, dont 82% ont été admis en service de chirurgie.Conclusion : Nos résultats peuvent guider les décideurs des hôpitaux de référence dans l'amélioration de la répartition des ressources et le choix de priorités en matière de besoins de santé publique liés au développement urbain ultérieur. Il y a un besoin urgent d'un plan complet de prévention des RTI, particulièrement parmi les piétons à Addis-Abeba.

Marco de referencia: El servicio de urgencias del Zewditu Memorial Hospital de Adís Abeba, en Etiopía.Objetivo: Verificar la proporción de los pacientes (⩾15 años de edad) que ingresaron al servicio de urgencias (ED) por traumatismos causados por el tránsito (RTI) y analizar las tendencias, las características y los desenlaces de estos casos del 2014 al 2015.Método: Fue este un estudio transversal realizado a partir de los datos corrientes recogidos retrospectivamente en el ED.Resultados: De los 10 007 ingresos al ED, 779 correspondieron a casos de RTI (8%); esta proporción fue más alta durante el mes de enero (11%). De estos casos, se pudo recuperar la historia clínica de 522 pacientes (67%). La mediana de la edad fue 28 años y el 69% de los pacientes era de sexo masculino. La mayoría de los pacientes eran peatones (69%) y la causa del accidente había sido un automóvil (78%). Tras la clasificación de los pacientes al ingreso, se consideró que el 32% precisaba una intervención urgente o inmediata. El traumatismo craneoencefálico fue la segunda lesión más frecuente (20%) después de las lesiones de los miembros inferiores (36%). Los desenlaces clínicos del ED fueron como sigue: alta (68%), hospitalización (17%), remisión (17%) y muerte (1%). De los 78 pacientes hospitalizados, el 62% ingresó al servicio de cirugía y el 16% al servicio de ortopedia. De los 146 casos de RTI con trauma craneoencefálico, 25% de los pacientes se hospitalizaron, de los cuales el 82% en el servicio de cirugía.Conclusión: Estos resultados pueden orientar a las instancias normativas de los hospitales de referencia a mejorar la planificación de los recursos hospitalarios y a priorizar las necesidades de salud pública en relación con el futuro desarrollo urbano. En Adís Abeba se precisa con urgencia un plan de prevención de los RTI a los peatones.

Preventable but neglected: rickets in an informal settlement, Nairobi, Kenya.

SETTING: The primary care clinics of Médecins Sans Frontières within the informal settlement of Kibera, Nairobi, Kenya. OBJECTIVE: To describe the demographic and clinical characteristics of children clinically diagnosed with rickets from September 2012 to October 2013. DESIGN: Descriptive retrospective case review of diagnosis and treatment course with vitamin D and calcium using routine programme data. RESULTS: Of the 82 children who met the clinical diagnosis of rickets, 57% were male, with a median age of 12 months and 14 months for females. Children with rickets were found to have ⩽3 hours/week sunlight exposure for 71% of the children and malnutrition in 39%. Clinical findings on presentation revealed gross motor developmental delays in 44%. The loss to follow-up rate during treatment was 40%. CONCLUSIONS: This study found that rickets is a common clinical presentation among children living in the informal settlement of Kibera and that there are likely multiple factors within that environment contributing to this condition. As rickets is a simply and inexpensively preventable non-communicable disease, we suggest that routine vitamin D supplementation be formally recommended by the World Health Organization for well-child care in Africa, especially in the contexts of informal settlements.

Contexte : Le dispensaire de soins de santé primaire de Médecins sans Frontières au cœur du bidonville de Kibera, Nairobi, Kenya.Objectif : Décrire les caractéristiques démographiques et cliniques d'enfants ayant eu un diagnostic clinique de rachitisme de septembre 2012 à octobre 2013.Schéma : Revue descriptive et rétrospective du diagnostic et du traitement par vitamine D et calcium à travers les données des programmes de routine.Résultats : Sur 82 enfants répondant au diagnostic clinique de rachitisme, 57% étaient des garçons d'un âge médian de 12 mois tandis que l'âge médian des filles était de 14 mois. L'exposition au soleil déclarée par la famille était de ⩽3 heures par semaine pour 71% des enfants et 39% présentaient une malnutrition. Les constatations cliniques à l'arrivée ont mis en évidence un retard de développement moteur marqué chez 44% des enfants. Le taux de perdus de vue pendant le traitement a été de 40%.Conclusion : Cette étude a constaté que le rachitisme était une affection fréquente parmi les enfants vivant dans le bidonville de Kibera et que de nombreux facteurs de l'environnement de Kibera y contribuaient vraisemblablement. Comme le rachitisme est une maladie non transmissible qui peut bénéficier d'une prévention simple et peu coûteuse, nous suggérons qu'une supplémentation en vitamine D soit formellement recommandée par l'Organisation Mondiale de la Santé dans les soins de santé aux enfants en Afrique, surtout dans le contexte de bidonvilles.

Marco de referencia: Los consultorios de atención primaria dirigidos por Médecins Sans Frontières en el asentamiento informal de Kibera, en Nairobi, Kenia.Objetivo: Describir las características clínicas y demográficas de los niños con diagnóstico clínico de raquitismo entre septiembre del 2012 y octubre del 2013.Método: Fue este un análisis descriptivo de casos, en el cual se evaluaron retrospectivamente el diagnóstico y la evolución del tratamiento con vitamina D y calcio, a partir de los datos corrientes del programa.Resultados: De los 82 niños que cumplían con los criterios diagnósticos de raquitismo, el 57% era de sexo masculino, con una mediana de edad de 12 meses y la mediana de edad de las niñas fue 14 meses. En el 71% los casos de raquitismo se encontró que la exposición directa al sol era de ⩽3 horas por semana y el 39% presentaba desnutrición. El examen físico en el momento de la consulta demostró un grave retraso del desarrollo motor en el 44% de los niños. Durante el seguimiento se perdió el 40% de los casos.Conclusiones: El presente estudio puso en evidencia que el raquitismo es una enfermedad frecuente en los niños que acuden a la consulta y viven en el asentamiento informal de Kibera; existen múltiples factores en el medio ambiente que contribuyen a esta situación. Dado que el raquitismo es una enfermedad no transmisible cuya prevención es sencilla y de bajo costo, se propone que la Organización Mundial de la Salud recomiende formalmente el aporte complementario sistemático de vitamina D en la consulta del niño sano en África, sobre todo en los entornos de asentamientos no estructurados.

Aberration corrected analytical electron microscopy studies of sol-immobilized Au + Pd, Au{Pd} and Pd{Au} catalysts used for benzyl alcohol oxidation and hydrogen peroxide production.

In this study, a systematic series of AuPd bimetallic particles were prepared by colloidal synthesis methods, in order to gain better control over the particle size distribution and structure. Particles having random alloy structures, as well as 'designer' particles with Pd-shell/Au-core and Au-shell/Pd-core morphologies, have been prepared and immobilized on both activated carbon and TiO2 supports. Aberration corrected analytical electron microscopy (ACEAM) has been extensively used to characterize these sol-immobilized materials. In particular, state-of-the-art z-contrast STEM-HAADF imaging and STEM-XEDS spectrum imaging has been employed. These techniques have provided invaluable new (and often unexpected) information on the atomic structure, elemental distribution within particles, and compositional variations between particles for these controlled catalyst preparations. In addition, we have been able to compare their differing thermal stability, sintering and wetting behaviors on activated carbon and TiO2 supports. These sol immobilized materials have also been compared as catalysts for (i) benzyl alcohol oxidation and (ii) the direct production of H2O2 in an attempt to elucidate the optimum particle morphology/ support combination for each reaction.

Upper airway collapsibility, dilator muscle activation and resistance in sleep apnoea.

The calibre of the upper airway is thought to be dependant upon its passive anatomy/collapsibility and the activation of pharyngeal dilator muscles. During awake periods, the more collapsible upper airway in obstructive sleep apnoea (OSA) increases the dilator muscle activity through a negative-pressure reflex. A direct correlation between the critical closing pressure (P(crit)), as a measure of anatomy/collapsability and electromyogram (EMG) activity of genioglossus EMG (GG-EMG) and tensor palatini EMG (TP-EMG), was hypothesised. The relationship between these indices and pharyngeal resistance (R(phar)) was also examined. The study involved eight males with a mean age of 48 (interquartile range 46-52) yrs with OSA, and an apnoea/hypopnoea index of 75 (65-101).hr(-1) on two nights breathing normally and on nasal continuous positive airway pressure (nCPAP). The P(crit )was measured during nonrapid eye movement sleep on nCPAP using brief, incremental reductions in mask pressure. GG-EMG and TP-EMG were measured breath-by-breath, awake, during sleep onset and on nCPAP. R(phar) was measured using airway pressures and flow. Wakeful GG-EMG, early sleep TP-EMG and the sleep decrement in TP-EMG were directly related to P(crit). Muscle activation was negatively correlated with R(phar) for TP-EMG awake and GG-EMG early in sleep. In conclusion these results confirm that dilator muscle activation is directly related to airway narrowing and reduces resistance across patients with obstructive sleep apnoea.

Genioglossal activation in patients with obstructive sleep apnea versus control subjects. Mechanisms of muscle control.

Pharyngeal dilator muscle activation (GGEMG) during wakefulness is greater in patients with obstructive sleep apnea (OSA) than in healthy control subjects, representing a neuromuscular compensatory mechanism for a more collapsible airway. As previous work from our laboratory has demonstrated a close relationship between GGEMG and epiglottic pressure, we examined the relationship between genioglossal activity and epiglottic pressure in patients with apnea and in control subjects across a wide range of epiglottic pressures during basal breathing, negative-pressure (iron-lung) ventilation, heliox breathing, and inspiratory resistive loading. GGEMG was greater in the patients with apnea under all conditions (p < 0.05 for all comparisons), including tonic, phasic, and peak phasic GGEMG. In addition, patients with apnea generated a greater peak epiglottic pressure on a breath-by-breath basis. Although the relationship between GGEMG and epiglottic negative pressure was tight across all conditions in both groups (all R values > = 0.69), there were no significant differences in the slope of this relationship between the two groups (all p values > 0.30) under any condition. Thus, the increased GGEMG seen in the patient with apnea during wakefulness appears to be a product of an increased tonic activation of the muscle, combined with increased negative-pressure generation during inspiration.

Chemical prevention of colony foundation by Cryptotermes brevis (Isoptera: Kalotermitidae) in attic modules.

Disodium octaborate tetrahydrate (DOT) dust, DOT aqueous solution, imidacloprid dust, and amorphous silica gel dust with synergized 1% pyrethrins were applied on wood surfaces to simulated attic modules. Modules (30 by 30 cm) with and without fiberglass insulation were exposed to dispersal flights of Cryptotermes brevis (Walker) in May and June of 1998 and 1999. Six months after flights, modules were disassembled and inspected for nuptial chamber location and contents. During both years, air and water control treatments contained 22.2+/-9.94 (mean +/- SD) nuptial chambers, 7.5+/-5.7 live imagos, and 2.0+/-1.4 chambers with brood. This survivorship indicated that the attic modules performed well as a colonizing platform for C. brevis. C. brevis dealates preferred constructing nuptial chambers in the crevices at the bases or tops of the modules instead of internal crevices. Modules treated in 1998 and 1999 with DOT or silica dusts contained no live termites, whereas zero of five modules treated with imidacloprid dust in 1998 and two of 20 modules treated with imidacloprid dust in 1999 contained single live incipient colonies. In 1998, 15% DOT solution, applied as a postconstruction treatment, yielded significantly fewer chambers and live termites than controls, but was not as effective as dusts in preventing successful colonization. In 1999, the DOT solution, applied as a construction-phase treatment, was equally as effective in preventing colonization as the dust treatments during that year. Results indicate that dust formulations of DOT, silica gel, and imidacloprid can be used to prevent drywood termite colonization in existing building voids and attics. Where the entire wood framing is exposed to treatment, such as during building construction, aqueous DOT solution can be equally effective as dusts in preventing colonization by C. brevis.

Genioglossal inspiratory activation: central respiratory vs mechanoreceptive influences.

Upper airway dilator muscles are phasically activated during respiration. We assessed the interaction between central respiratory drive and local (mechanoreceptive) influences upon genioglossal (GG) activity throughout inspiration. GG(EMG) and airway mechanics were measured in 16 awake subjects during baseline spontaneous breathing, increased central respiratory drive (inspiratory resistive loading; IRL), and decreased respiratory drive (hypocapnic negative pressure ventilation), both prior to and following dense upper airway topical anesthesia. Negative epiglottic pressure (P(epi)) was significantly correlated with GG(EMG) across inspiration (i.e. within breaths). Both passive ventilation and IRL led to significant decreases in the sensitivity of the relationship between GG(EMG) and P(epi) (slope GG(EMG) vs P(epi)), but yielded no change in the relationship (correlation) between GG(EMG) and P(epi). During negative pressure ventilation, pharyngeal resistance increased modestly, but significantly. Anesthesia in all conditions led to decrements in phasic GG(EMG), increases in pharyngeal resistance, and decrease in the relationship between P(epi) and GG(EMG). We conclude that both central output to the GG and local reflex mediated activation are important in maintaining upper airway patency.

Phasic mechanoreceptor stimuli can induce phasic activation of upper airway muscles in humans.

1. Upper airway dilator muscles are phasically activated throughout breathing by respiratory pattern generator neurons. Studies have shown that non-physiological upper airway mechanoreceptive stimuli (e.g. rapidly imposed pulses of negative pressure) also activate these muscles. Such reflexes may become activated during conditions that alter airway resistance in order to stabilise airway patency. 2. To determine the contribution of ongoing mechanoreceptive reflexes to phasic activity of airway dilators, we assessed genioglossal electromyogram (GG EMG: rectified with moving time average of 100 ms) during slow (physiological) oscillations in negative pressure generated spontaneously and passively (negative pressure ventilator). 3. Nineteen healthy adults were studied while awake, during passive mechanical ventilation across normal physiological ranges of breathing rates (13-19 breaths min-1) and volumes (0.5-1.0 l) and during spontaneous breathing across the physiological range of end-tidal carbon dioxide (PET,CO2; 32-45 mmHg). 4. Within-breath phasic changes in airway mechanoreceptor stimuli (negative pressure or flow) were highly correlated with within-breath phasic genioglossal activation, probably representing a robust mechanoreceptive reflex. These reflex relationships were largely unchanged by alterations in central drive to respiratory pump muscles or the rate of mechanical ventilation within the ranges studied. A multivariate model revealed that tonic GG EMG, PET,CO2 and breath duration provided no significant independent information in the prediction of inspiratory peak GG EMG beyond that provided by epiglottic pressure, which alone explained 93 % of the variation in peak GG EMG across all conditions. The overall relationship was: Peak GG EMG = 79.7 - (11.3 X Peak epiglottic pressure), where GG EMG is measured as percentage of baseline, and epiglottic pressure is in cmH2O. 5. These data provide strong evidence that upper airway dilator muscles can be activated throughout inspiration via ongoing mechanoreceptor reflexes. Such a feedback mechanism is likely to be active on a within-breath basis to protect upper airway patency in awake humans. This mechanism could mediate the increased genioglossal activity observed in patients with obstructive sleep apnoea (i.e. reflex compensation for an anatomically smaller airway).

Reed bed dewatering of agricultural sludges and slurries.

In trials at Rugeley, UK, reed beds were used for dewatering agricultural sludges and slurries. Three beds, each of 3.5 m2, were employed, two planted with Phragmites australis, the third left unplanted as control. The sludge contained partly oxidised solids from a Biological Aerated Filter (BAF) treating weak pig slurry. It was supplemented with untreated settled pig slurry. Following reed establishment planted Bed A was fed at a constant similar rate to the unplanted Control Bed C. The second planted Bed B was fed at higher rates alternating with rest periods. On this bed the aeration pipes were blocked off. The trials were run for 16 months, which included two summer periods. The results showed that the planted Bed A had definitely better dewatering ability than the unplanted one fed at a similar rate. During the summer months Bed B could be fed at over twice the rate used for the constant input beds. The percolate from the control bed was more highly oxidised than from the planted beds, probably due to a longer holdup time in the absence of reeds. On Bed B the reed quality deteriorated during the second year, after use of untreated slurry as feed.

Genioglossal but not palatal muscle activity relates closely to pharyngeal pressure.

The stimuli controlling pharyngeal dilator muscles are poorly defined. Local mechanoreceptors are a leading possibility. To address this, we assessed the relationship between two dilator muscle electromyograms (EMGs, i.e., genioglossus [GG-an inspiratory phasic muscle], tensor palatini [TP-a tonically active muscle]) and potential stimuli (i.e., epiglottic pressure [Pepi], airflow [V], and pharyngeal resistance [Rpha]). Fifteen normal subjects were studied, during wakefulness and stable non-rapid eye movement (NREM) sleep. The GGEMG and TPEMG were assessed during basal breathing and during inspiratory resistive loading (four loads, done in triplicate), while quantifying Pepi and choanal pressures (Pcho, Millar catheters) plus V. There was a strong correlation between Pepi and GGEMG during wakefulness in most subjects (9 of 15 had absolute R > 0.7 [p < 0.05], group mean R = -0.62, p < 0.05). These correlations were less robust during NREM sleep (8 of 15 absolute R > 0.6 [p < 0.05], group mean R = -0.39, ns). The slope of the Pepi versus GGEMG relationship was greater during wakefulness than sleep (-0.67 versus -0.39% max/ cm H(2)O, p < 0.05). No significant correlations were observed between TPEMG and any of the measured potential stimuli. We conclude that intrapharyngeal pressure may modulate genioglossus activity during wakefulness, with a fall in muscle responsiveness during sleep. The activity of the TP was not clearly influenced by any measured local stimulus either awake or asleep.

Influence of chemoreceptor stimuli on genioglossal response to negative pressure in humans.

Genioglossal muscle (GG) activity is modulated by both chemoreceptive and mechanoreceptive reflexes that help stabilize airway patency. We assessed the effects of blood gas changes, within the range encountered during mild obstructive apnea-arousal cycles, on GG activity and the GG reflex to upper airway negative pressure. Eighteen healthy adults were studied while awake under 5 conditions: (1) baseline (PET(CO(2)) = 40 mm Hg, Sa(O(2)) = 99%); (2) hypercapnia (PET(CO(2)) = 45 mm Hg); (3) hypocapnia (PET(CO(2)) = 35 mm Hg, induced via hyperventilation with an iron lung ventilator); (4) hypoxia (Sa(O(2)) = 87%); and (5) hypercapnia plus hypoxia (PET(CO(2)) = 45 mm Hg, Sa(O(2)) = 87%). Measurements included airflow, choanal and epiglottic pressures (Pchoa and Pepi), upper airway resistance, phasic and tonic GG EMG, and the GG reflex to negative pressure (Pchoa = -12.5 cm H(2)O). Ventilation increased from a baseline of 10.7 up to 22.7 L. min(-1) under conditions of altered blood gases. Peak inspiratory phasic GG EMG increased from 6. 5 to 11.1% of maximal contraction but there were no significant changes in either tonic GG EMG (range, 4.3 to 5.8% of maximum) or magnitude of the GG reflex (range, 4.1 to 5.5% of maximum). Among conditions there was a high correlation between upper airway pressures and peak phasic GG EMG (Pchoa, r = 0.97, p < 0.01; Pepi, r = 0.87; p = 0.06). We conclude that in this range of blood gases: (1) the GG reflex to negative pressure is unchanged; (2) slow airway pressure changes throughout inspiration, generated either actively or passively, influence GG EMG activity; and (3) mechanoreceptive control of GG EMG can fully explain all changes in GG activity, suggesting that chemoreceptive inputs to GG are minimal, or are not simply summated with mechanoreceptor inputs.

The influence of a transmucosal cholinergic agonist on pharyngeal muscle activity.

STUDY OBJECTIVE: To assess the effect of high local oral nicotine administration on the upper airway (UA) of normal males during wakefulness. DESIGN: Nonrandomized study. SETTING: Brigham & Women's Hospital General Clinical Research Center. PARTICIPANTS: Two groups of 13 and 12 normal male subjects were evaluated. INTERVENTIONS: A "Fast acting" or "Intermediate acting" 2 mg transmucosal nicotine patch was attached to an upper molar tooth of study participants during wakefulness. MEASUREMENTS: All data were collected prior to, and at several time points after, patch placement. Data measured included serum nicotine levels, genioglossal EMG, and pharyngeal resistance during basal breathing as well as the UA muscle response and UA collapsibility during negative UA pressure pulses. RESULTS: None of the variables measured showed a statistically significant change with either nicotine patch despite a significant rise (p<0.05) in nicotine serum levels post patch placement in both groups. In several subjects, muscle activity and responsiveness to negative pressure increased after application of both patches and returned to near baseline levels at the last time point measured, a response consistent with the time course of nicotine release in both patches. CONCLUSIONS: Oral nicotine administration failed to consistently increase GG muscle activation which may be a problem of local bioavailability of nicotine in the muscle.

Local mechanisms drive genioglossus activation in obstructive sleep apnea.

Individuals with obstructive sleep apnea (OSA) require increased pharyngeal muscle dilator activation during wakefulness to maintain upper airway patency. Negative pressure is one potential stimulus for this neuromuscular compensation. Individuals with OSA who have previously undergone tracheostomy provide an opportunity to study upper airway physiology in both the presence and absence of upper airway respiratory stimuli. If negative pressure (or another local airway stimulus) were important in driving pharyngeal dilator muscle activation, one would predict that during nasal breathing, the pharynx of a tracheostomized patient would be exposed to negative pressure, and that high levels of muscle activation would therefore be measured. Conversely, during breathing by the patient through the tracheal stoma, one would expect low levels of muscle activation in the absence of local stimuli. We measured a number of respiratory variables, including genioglossus activation under both nasal and tracheal stomal breathing conditions, in five patients. In all five patients there was a significant and substantial decrease in both peak phasic (100 +/- 0 to 53.4 +/- 9.2 arbitrary units [mean +/- SEM], p < 0.01) and tonic genioglossus activation (36.3 +/- 5.3 to 20.7 +/- 3.9 arbitrary units, p < 0.05) during stomal breathing as compared with nasal breathing. We conclude that local upper airway respiratory stimuli, possibly negative pressure, are important in mediating the increased pharyngeal dilator muscle activation seen in sleep apnea patients during wakefulness.

Reduced genioglossal activity with upper airway anesthesia in awake patients with OSA.

We examined whether topical upper airway anesthesia leads to a reduction in genioglossal (GG) electromyogram (EMG) in patients with obstructive sleep apnea (OSA). Airway mechanics were also evaluated. In 13 patients with OSA, we monitored GG EMG during tidal breathing and during the application of pulses of negative airway pressure (-10 to -12 cmH(2)O). Airflow resistance and airway collapsibility were determined. All measurements were performed with and without topical anesthesia (lidocaine). Anesthesia led to a significant fall in the peak GG EMG response to negative pressure from 36.1 +/- 4.7 to 24.8 +/- 5.3% (SE) of maximum (P < 0.01). This was associated with a fall in phasic and tonic EMG during tidal breathing (phasic from 24.4 +/- 4.1 to 16.4 +/- 3.4% of maximum and tonic from 10.9 +/- 1.6 to 8.0 +/- 1.3% of maximum, P < 0.01). A significant rise in pharyngeal airflow resistance was also observed. Our results demonstrate that topical receptor mechanisms in the nasopharynx importantly influence dilator muscle activity and are likely important in driving the augmented dilator muscle activity seen in the apnea patient.