Predictive factors for recurrence of cryptoglandular fistulae characterized by preoperative three-dimensional endoanal ultrasound.

AIM: Precise information regarding the location of an anal fistula and its relationship to adjacent structures is necessary for selecting the best surgical strategy. Retrospective and cross-sectional studies were performed to determine predictive factors for recurrence of anal fistula from preoperative examination by three-dimensional endoanal ultrasound (3D-EAUS). METHOD: Patients in our tertiary centre and in a private centre specialized in proctology undergoing preoperative 3D-EAUS for cryptoglandular anal fistulae between 2002 and 2012 were included. A questionnaire was sent in September 2013 to assess the patient's condition with regard to recurrence. Variables checked for association with recurrence were gender, type of centre, previous fistula surgery, secondary track formation and classification of the fistula. RESULTS: There were 143 patients of whom 96 had a low fistula treated by fistulotomy, 28 a high fistula treated by fistulectomy and 19 a high fistula treated by fistulectomy combined with a mucosal advancement flap. The median duration of follow-up was 26 (2-118) months. The fistula recurred in 40 (27%) patients. Independent risk factors included the presence of secondary track formation [hazard ratio 2.4 (95% CI 1.2-51), P = 0.016] and previous fistula surgery [hazard ratio 1.2 (95% CI 1.0-4.6), P = 0.041]. Agreement between the 3D-EAUS examination and the evaluation under anaesthesia regarding the site of the internal opening, classification of the fistula and the presence of secondary tracks was 97%, 98% and 78%. CONCLUSION: The identification of secondary tracks by preoperative 3D-EAUS examination was the strongest independent risk factor for recurrence. This stresses the importance of preoperative 3D-EAUS in mapping the pathological anatomy of the fistula and a thorough search for secondary track formation during surgery.

El cambio climático, la salud humana y el desarrollo sostenible / Climate change, human health, and sustainable development

El cambio climático debido a actividades humanas pone en peligro los ecosistemas y la salud humana a escala mundial. Con el fin de hacer frente a las amenazas que se ciernen sobre los ecosistemas en todo el mundo, en el decenio de 1980 se introdujo el concepto del desarrollo sostenible. Desde entonces, ese concepto se ha aplicado ampliamente para guiar y enfocar la formulación de políticas. En el presente artículo se examinan las consecuencias sanitarias que tiene el cambio climático debido a actividades humanas para el desarrollo sostenible, en particular su posible efecto en el abastecimiento de alimentos, los desastres naturales, las enfermedades infecciosas, los ecosistemas y la elevación del nivel del mar. Se discute un modelo integrado que contiene los principales indicadores del desarrollo sostenible. También se examina la importancia que tienen el cambio climático, la salud humana y el desarrollo sostenible para las políticas internacionales pertinentes.

Human-induced climate change threatens ecosystems and human health on a global scale. In order to withstand the worldwide threats to ecosystems, the concept of sustainable development was introduced during the 1980s. Since then, this concept has been widely applied to guide and focus policy-making. The present article reviews the health consequences of human-induced climate change on sustainable development, particularly the potential impact of such change on food supply, natural disasters, infectious diseases, ecosystems, and sea level rise. Discussed is an integrated model containing the key indicators of sustainable development. The relevance of climate change, human health, and sustainable development for international climate change policy is also examined.

Climate change, human health, and sustainable development.

Human-induced climate change threatens ecosystems and human health on a global scale. In order to withstand the worldwide threats to ecosystems, the concept of sustainable development was introduced during the 1980s. Since then, this concept has been widely applied to guide and focus policy-making. The present article reviews the health consequences of human-induced climate change on sustainable development, particularly the potential impact of such change of food supply, natural disasters, infectious diseases, ecosystems, and sea level rise. Discussed is an integrated model containing the key indicators of sustainable development. The relevance of climate change, human health, and sustainable development for international climate change policy is also examined.

Vector-borne disease problems in rapid urbanization: new approaches to vector control.

Owing to population growth, poor levels of hygiene, and increasing urban poverty, the urban environment in many developing countries is rapidly deteriorating. Densely packed housing in shanty towns or slums and inadequate drinking-water supplies, garbage collection services, and surface-water drainage systems combine to create favourable habitats for the proliferation of vectors and reservoirs of communicable diseases. As a consequence, vector-borne diseases such as malaria, lymphatic filariasis and dengue are becoming major public health problems associated with rapid urbanization in many tropical countries. The problems in controlling these diseases and eliminating vectors and pests can be resolved by decision-makers and urban planners by moving away from the concept of "blanket" applications of pesticides towards integrated approaches. Sound environmental management practices and community education and participation form the mainstay of some of the most outstanding successes in this area. On the basis of these examples, it is argued that the municipal authorities need to apply a flexible methodology, which must be based on the possibilities of mobilizing community resources, with minimal reliance on routine pesticidal spraying. In this way, vector control becomes a by-product of human development in the city environment. This is now a true challenge.

PIP: Rural-urban migration and population growth are occurring more quickly now than ever before in history. These phenomena have resulted in overcrowded urbanization and increased densities of vectors which in turn have caused an increase in disease such as malaria and dengue and dengue hemorrhagic fever. Besides urban areas foster the breeding of mosquitoes, rats, and other pests. Further governmental services in both developed and developing countries have not been able to keep up with housing and sanitation needs. Moreover new migrants continue to move into temporary housing (slums) made of inferior materials with no services while the previous occupants improve their wages and move on to better housing. Thus little incentive exists to improve slums where sanitation is poor and disease common. In addition, many formerly rural people continue rural practices and traditions in urban areas such as patterns of water storage. Further people often try to control vectors by applying pesticides, but do so haphazardly and/or in an unsafe, uncontrolled manner. They even use empty pesticide containers for storing water or food. Besides insecticide resistance is spreading. WHO encourages governments to integrate disease control programs with primary health care, but most such integrated programs operate in developed countries. Integrated approaches include less dependence on pesticides; encouraging changes in human behavior; disseminating health messages; community participation, particularly the youth; mobilization of human and financial resources; and proper urban development, e.g., better quality housing and adequate sanitation and potable water.

Medical aspects of lay resuscitations in Rotterdam.

In the Rotterdam system of prehospital care for patients with circulatory failure, the cardiopulmonary resuscitation (CPR) training programme for lay persons contributes to the first link in the chain of care, i.e. the period of time spent awaiting the arrival of professional staff. In this paper we describe some of the medical aspects of this programme. The material used was obtained in a study of 5312 trainees who had followed a CPR course. Case histories were reconstructed of 91 victims who had been resuscitated by 109 respondents. At least 20% of resuscitated persons had collapsed as a result of non-cardiac causes. In this category the longer term survival rates were relatively the most favourable. In several instances the indication for resuscitation had been incorrect, while the technical proficiency in the delivery of CPR was often inadequate. We conclude that one course is insufficient for the development of the required 'skill'. We also conclude that the courses should dwell more elaborately on the non-cardiac causes of collapse, particularly in training programmes addressing the public at large. Attention is drawn to the need of designing and implementing special courses for family members and relatives of persons known to be cardiac patients. The need for continuing evaluation, involving active contributions from lay resuscitators, is underlined.

The control of malaria vectors in the context of the Health for All by the Year 2000 Global Strategy.

The changing picture of malaria worldwide needs to be viewed in the context of other developments before we can determine the directions to take to be able to provide the thrusts required in malaria vector control. As a result of population growth, increasing urbanization and continuing pressure on scarce natural resources, the epidemiology of malaria and its manifestation as a public health problem are undergoing profound modifications, indeed in several parts of the world. This picture is further complicated by the spread of resistance to pesticides in the vector and to drugs in Plasmodium falciparum. In the immediate future, these trends will continue. In addition, the appearance of suitable vaccines is a highly probable event to be taken into consideration. The WHO Global Strategy of Health For All by the Year 2000 aims at the improvement of levels of health through primary health care. Among other things, this implies a greater reliance on community involvement and on intersectoral collaboration for health. In this light, the major malaria problems in the year 2000 will be: (1) "hard core" endemic areas with inadequate infrastructure and poor socio-economic development; (2) resource development areas, in particular those under illegal or poor controlled exploitation; (3) expanding urban areas and (4) increased mobility of non-immunes, particularly if uncontrolled. In order to cope with these problems, thrusts are required towards the development of vector control strategies, covering the following fields: (1) tools for vector control integrated in primary health care, (2) new chemicals, (3) improved and new biologicals, (4) environmental management and the adoption of health safeguards in resource development projects and (5) manpower development.

Machakos project studies. Agents affecting health of mother and child in a rural area of Kenya. XXII. Schistosomiasis transmission in relation to some socio-economic and other environmental factors.

A schistosomiasis research project, carried out in part of the Machakos area, yielded data by which it was possible to relate household egg outputs to some socioeconomic and other environmental variables. A significant negative correlation with schistosome scores was found for most variables when tested individually. Multiple regression analysis revealed a relatively strong relation with altitude and a much weaker association with some other variables. It is discussed whether the influence of altitude may be explained by differences in temperature, 'distance from infected water', or both. Furthermore it is hypothesized whether relations with social and economical variables are due to the fact that members of wealthier families stay away from contaminated water more often, have more knowledge of schistosomiasis and differ in hygienic behaviour.

Ovarian development and biting frequency in Anopheles culicifacies Giles in Sri Lanka.

In order to determine the duration of the gonotrophic cycle in Anopheles culicifacies Giles in Sri Lanka, ovarian development in freshly blood-fed wild-caught females was studied in the laboratory and the findings were compared with mark-and-release recoveries in the field. In specimens of unknown parity at first capture probable feeding intervals of 1, 2 and 3 days (mean: 1.7 - 2.1 days) were found. The release of freshly blood-fed nullipars bred from larvae produced two recaptures from which it could be concluded that the time required to become parous need not be more than three days. These results are of consequence in the assessment of the efficacy of insecticide spraying as an anti-malarial measure in Sri Lanka and possibly in other countries in South Asia where A. culicifacies is the vector. An equation is proposed for deriving the mosquito's daily survival rate (p) from the proportion of parous females in biting samples.

Machakos Project Studies: Agents affecting health of mother and child in a rural area of Kenya. XV. The economic setting at the household level.

In 1974 a household survey on economic conditions was carried out in about 80% of all households in the Machakos Project study area. This survey formed a part of an investigation into determinants of health and disease in children below five years of age. This paper deals with some background information, the field methodology employed, the construction of variables and the differences found between the eastern and western parts of the area in respect of some of these variables. The results are compared with those from in-depth sample studies carried out earlier.

Machakos Project Studies. Agents affecting health of mother and child in a rural area of Kenya. VI. The social and hygienic environment.

As part of an investigation into determinants of health and disease in children below five years old, a household survey on social and hygienic conditions was carried out in the Machakos Project area. This paper deals with the field methodology of the survey, the selection of variables from the material collected and the differences between the eastern and western parts of the area in respect of the variables selected. In later issues of the Machakos Project Studies, the data obtained will be related to those from other cross-sectional surveys as well as to findings on morbidity and mortality in the child population.