Topographical Differences of Infant Mortality in Nepal.

Background Infant mortality is a major problem in Nepal, particularly in the mountainous region of the country. Objective To identify factors that contributes to the high rate of infant mortality in the mountain zone in Nepal. Method Data were derived from the 2011 Nepal Demographic and Health Survey (NDHS). Infant mortality was analyzed across three ecological zones in a sample of 5,306 live births in the five years preceding the survey. The contribution of risk factors to the excess infant mortality was assessed using multiple logistic regression. Result Infant mortality rate (deaths per 1000 live births) in the ecological zones were 59 (95% CI: 36, 81), 44 (35, 53), and 40 (33, 47) for the mountain, hill and terai zones, respectively. Women living in the mountain zone were more likely to report that distance to care was a "big problem" and had a greater risk of infant mortality compared to the terai zone (OR=1.42, 95% CI: 1.01, 2.02, p=0.04). This increased risk was observed only among births to mothers who perceived distance to the nearest health facility as a "big problem" (aOR=1.57, 95% CI: 1.01, 2.40, p=0.04) controlling for other risk factors. Conclusion These findings suggest that the higher Infant mortality rate (IMR) in the mountain zone was among the women who perceived distance to health facilities as a big problem. Improved accessibility to health services, particularly in this zone, is an essential strategy for reducing infant mortality in Nepal.

Primate encephalization and intelligence.

The amount of brain mass exceeding that related to an animal's total body mass is called encephalization. And quantifying encephalization has been argued to be directly related to an animal's level of intelligence. In this study, the legitimacy of the encephalization hypothesis was tested for encephalization slopes 0.28, 0.67, and 0.75 in Snell's equation of simple allometry by determining the intersexual encephalization similarity for humans and 18 other primate species and by comparing the encephalization quotients for humans and six other primate species against the learning ability evaluations for their intelligence. Results suggest that the most accurate means for quantifying the encephalization of humans and other adult primate species requires the use of Lapicque's universal exponent of 0.28 in Snell's equation of simple allometry. Since Lapicque's slope was derived from various vertebrate groups, this equation may potentially be universally applicable for determining relative adult vertebrate encephalization and intelligence.

Oncologic rationale for bilateral tonsillectomy in head and neck squamous cell carcinoma of unknown primary source.

OBJECTIVE: To demonstrate an oncologic basis for the recommendation to perform bilateral tonsillectomy as a routine measure in the search for a primary mucosal lesion in patients presenting with cervical nodal metastasis of squamous cell carcinoma (SCC). STUDY DESIGN: A case series of individuals selected from a 3-year period is reported. SETTING: Academic medical center. RESULTS: Each individual presented with metastatic squamous cell carcinoma in a cervical lymph node from an unknown primary source. In each case, the primary source was identified in a tonsillectomy specimen, either located contralateral to the node, or in both tonsils. CONCLUSIONS: The rate of contralateral spread of metastatic cancer from occult tonsil lesions appears to approach 10%. For this reason, bilateral tonsillectomy is recommended as a routine step in the search for the occult primary in patients presenting with cervical metastasis of SCC and palatine tonsils intact.

Vocal fold paralysis after anterior cervical diskectomy and fusion.

OBJECTIVE: The anterior approach to the cervical spine now serves as the surgical access of choice for cervical spine disease. Vocal fold paralysis (VFP) may follow the procedure as a complication. The authors describe their experience with patients having VFP after anterior cervical diskectomy and fusion (ACDF), with an emphasis on outcome and prognosis. STUDY DESIGN: Retrospective. METHODS: Medical records of patients who underwent ACDF between January 1987 and February 1998 were reviewed. Further detailed review of the patients with documented VFP after surgery was then performed. RESULTS: Over the given time period 411 ACDFs were performed and 21 patients with this complication were identified (5%). All 21 patients had right-sided approaches. Eighteen patients had right VFP, 2 had left VFP, and 1 had bilateral VFP. Symptoms included hoarseness (18), persistent cough (7), aspiration (13), and dysphagia (7). The patient with bilateral VFP presented with stridor and respiratory distress requiring tracheotomy. The complete records of 17 patients with 18 VFPs were available for review. Fifteen of 18 VFPs (83.3%) had complete resolution within 12 months. One patient had recovery after 15 months. All patients were treated conservatively with speech and swallowing therapy. One patient required Gelfoam injection and another medialization thyroplasty, both for aspiration symptoms. CONCLUSIONS: The data suggest that at least 80% of VFP after ACDF will recover within 12 months of the procedure. The authors recommend regular follow-up and speech therapy for symptomatic patients. Medialization should be considered in patients with aspiration or persistent problems.

Sialolithiasis.

Sialolithiasis is one of the most common problems that afflict the salivary glands and is a major cause of salivary gland dysfunction. Sialolithiasis is frequently encountered in clinical practice. The mechanism for stone formation is incompletely understood. The clinical diagnosis and standard management of sialolithiasis are discussed, and new modalities for treatment are also presented in this article.

Timing of percutaneous endoscopic gastrostomy tube placement in head and neck cancer patients.

Percutaneous endoscopic gastrostomy (PEG) is an effective method for providing alimentation in patients with upper aerodigestive tract carcinoma. Multiple complications of this procedure have been reported, ranging from leakage around the tube to tumor seeding of the abdominal cavity. This study was undertaken to determine whether the timing of PEG tube placement with respect to primary tumor extirpation led to a difference in the number and severity of observed complications. The medical records of 43 patients with head and neck carcinoma who had PEG tubes placed from 1995 to 1996 were retrospectively reviewed. Comparisons of timing of PEG tube placement, complication, location, and stage of the primary tumor were performed. In addition, the use of adjuvant therapy with respect to the time of PEG tube placement and complications was evaluated. Of these, 23% were done before and 30% during surgery at the time of primary tumor resection (9 of 13 were after primary removal). One patient had an intraabdominal abscess. Minor complications occurred in 15 of 43 patients (35%) and included granulation tissue at the PEG site, leakage, and tube displacement. Eight of the 9 patients who underwent intraoperative PEG after tumor resection had no complications. Patients who underwent PEG during or after surgery had significantly fewer complications than those who underwent preoperative PEG or had unresectable tumors (P = 0.038). The largest number of complications occurred in patients who underwent preoperative PEG (57%) followed by patients whose tumors were unresectable (31%). There was no statistical difference with regard to tumor location or postoperative x-ray therapy in PEG complications. This study demonstrates that PEG tube placement after tumor resection has the lowest incidence of postoperative complications. Performing PEGs intraoperatively after tumor resection can prevent the need for additional anesthesia to provide alimentation in patients with upper aerodigestive tract carcinoma.

Cervical spine injury complicating facial trauma: incidence and management.

PURPOSE: To review the impact of concomitant cervical spine injury on the management of facial fractures in a tertiary care institution via a retrospective chart review. PATIENTS AND METHODS: Within the past 10 years, 1,750 consecutive patients presented to our institution with facial fractures. Thirty-two had concomitant cervical spine injury. Five were transferred or died before treatment. The remaining 27 charts were reviewed in detail. RESULTS: The incidence of cervical spine injury among patients with facial fractures in our study was 1.8%. There were no treatment delays attributed to these injuries. Of note was the inaccuracy of lateral cervical spine films in 9 of 27 cases (33%). CONCLUSION: Although uncommon, cervical spine injury must be thoroughly ruled out before evaluation and management of facial trauma. Concomitant cervical spine injury should not delay appropriate and timely treatment of facial fractures because adequate means of intraoperative stabilization are readily available.

Detection of cervical metastasis. A meta-analysis comparing computed tomography with physical examination.

BACKGROUND: Despite extensive coverage in recent literature, controversy continues with regard to the relative sensitivities of computed tomography (CT) and physical examination (PE). OBJECTIVE: To identify a statistically significant consensus. DATA SOURCES: Initially, data were reviewed on 47 consecutive patients with head and neck cancer on whom a total of 53 neck dissections were performed. These data were combined with findings from a 15-year MEDLINE review of the English-language literature, including references. STUDY SELECTION: All publications that contained a direct comparison of CT with PE, with appropriate data availability, were included. DATA EXTRACTION: Multiple-observer independent extraction was used. A total of 647 neck dissections were included in the meta-analysis. The definition of metastasis varied minimally among studies as follows: (1) nodal size, greater than 10 to 15 mm; (2) multiplicity of 8- to 10-mm nodes; or (3) evidence of necrosis. Necks were compared for positivity or negativity rather than for the actual nodal staging. In all cases, a final determination was made by results of histopathologic examination of surgical specimens. DATA SYNTHESES: The results in this review favored CT over PE but were not statistically significant by use of the Fisher exact test. A combination of the present study's data with those of the literature review yielded the following meta-analysis results: sensitivity, 83% (CT) vs 74% (PE) (P = .002); specificity, 83% (CT) vs 81% (PE) (P = .7); and accuracy, 83% (CT) vs 77% (PE) (P = .006). Overall, PE identified 75% of pathologic cervical adenopathy; this detection rate increased to 91% with the addition of CT. The results of sensitivity analysis confirmed homogeneity across study designs. CONCLUSIONS: Computed tomography is a more sensitive indicator of cervical metastasis than PE. More importantly, these diagnostic modalities were additive, with CT significantly enhancing the detection rates of PE alone. All patients who are at risk for cervical metastasis should have CT or equivalent radiographic imaging performed prior to therapeutic intervention. Future studies correlating CT detection rates to the primary site and staging are needed before more specific conclusions can be drawn.

Violence and sexual harassment: impact on registered nurses in the workplace.

This study sought to determine the prevalence and impact of violence and sexual harassment experienced by registered nurses (RNs) in their workplaces in Illinois. A random sample of 1,130 RNs were selected to participate in the mail survey. The instrument used was the Nurse Assault Survey originally developed by the Nurse Assault Project Team in Ontario, Canada, and modified by the author. Three hundred forty-five subjects completed the survey (response rate: 30%). Fifty-seven percent of those responding reported personal experience with some aspect of sexual harassment, and 26% reported being victimized by physical assault while on the job. About one third of those who indicated they had been sexually harassed also had been physically assaulted. Patients/clients were the most frequent perpetrators of sexual harassment and physical assault, while physicians committed over half of the sexual assaults. Bivariate analysis showed a significant relationship between physical assault and levels of job satisfaction. A significant relationship also was found between sexual harassment and levels of job satisfaction. Results demonstrate that nurses need to take and active role in fostering a work environment free from violence and sexual harassment. They should be knowledgeable about institutional policies and, where none exist, they should work with administrators to develop them. Prevention and intervention programs should be developed for both student and registered nurses.

Sub-chronic administration of ethanol to mice does not modify the inhibitory effects of dieldrin, abamectin and the dihydropyrazole RH-3421 at their respective sites of action in the nervous system.

1. The potential influence of sub-chronic ethanol treatment on the ability of three chemical classes of insecticide to interact with their neuronal sites of action has been investigated in mouse brain. 2. Ethanol administration did not influence the inhibitory effects of either the cyclodiene dieldrin or the avermectin abamectin as determined by inhibition of GABA-stimulated chloride uptake. 3. Likewise there was also no discernable change in the sensitivity of sodium channels to inhibition by dihydropyrazole RH-3421 with sub-chronic ethanol treatment as assessed indirectly using a membrane potential assay. 4. The results of this study indicate that short term dietary exposure to ethanol fails to cause functional changes to the primary target sites of cyclodienes, avermectins and dihydropyrazoles in the mammalian central nervous system.

Neck needle foreign bodies in intravenous drug abusers.

Intravenous drug abusers often resort to deep cervical venous access if peripheral access is problematic. Deep cervical injection can occasionally result in needle breakage and needle foreign body. The records of 50 patients with neck needle foreign bodies related to intravenous drug abuse treated at The Johns Hopkins Hospital were reviewed retrospectively. Only half of these patients presented to this hospital with a complaint of a neck needle. Complications related to neck needles were manifested in 5 (10%) of the patients at the time of initial presentation. No delayed complications occurred. Human immunodeficiency virus seropositivity for this group of patients was 77% compared to a rate of 29% for all intravenous drug abusers at the same institution. The demographics and management of neck needle foreign bodies are discussed, and the importance of recognition of neck needle foreign bodies is emphasized.

Influence of gastrointestinal site of drug delivery on the absorption characteristics of ranitidine.

The absorption characteristics of ranitidine after delivery to three locations in the gastrointestinal tract were compared in an open-label study of eight healthy males. Subjects received ranitidine HCl (150 mg) for injection via a nasoenteric tube directly into their stomach, jejunum, or cecum sequentially in three separate periods (24 hr apart). Plasma samples were collected at periodic time intervals for 12 hr following each dosing and analyzed for ranitidine concentration by high-pressure liquid chromatography. Mean concentrations following cecal dosing were lower (P less than 0.05) than concentrations following gastric or jejunal dosing at each sampling time except baseline. Mean concentrations following gastric and jejunal dosing were similar except at 2 hr (gastric greater than jejunal). Mean pharmacokinetic parameters for cecal administration were different (P less than 0.05) from either the gastric or the jejunal periods with the exception of Tmax. There was no difference in any pharmacokinetic parameter after gastric or jejunal dosing. The relative bioavailability after cecal administration was less than 15% of that observed after administration into the stomach or jejunum. Additionally, Wagner-Nelson analysis indicated that the rate of ranitidine absorption was much slower following cecal administration than after gastric or jejunal dosing. Two plasma concentration peaks were observed in three of eight subjects after gastric dosing, in eight of eight subjects after jejunal dosing, and in zero of eight subjects after cecal dosing. These data demonstrate that the absorption profile of ranitidine is equivalent, in extent and duration, after delivery to the stomach or jejunum, while absorption from the cecum is significantly less.(ABSTRACT TRUNCATED AT 250 WORDS)

The relationship between health habits and health interests of students and employees in a nontraditional university.

This study investigated the health interests of students and full-time employees of a small, nontraditional university, and examined the relationships between selected health habits and correlated health interests. Health habits were assessed using the Wellness Check for Adults developed by the Rhode Island Health Department, and interest in health promotion programs was ascertained by the Health Interests Survey modified by the investigator. Significant (p < .05) differences between students and employees were found in their interest in 5 of the 11 health promotion programs listed. Responses to ranking 3 programs of most interest revealed that for students, exercising, weight control, and nutrition were prioritized, whereas employees ranked managing stress, nutrition, and weight control. Results of bivariate analyses (Mann-Whitney U) relating health habits to specific health interests varied in direction of association and significance. The results suggest a need to ask potential participants what health promotion programming they would be interested in attending rather than developing programs based only on identified health risk behaviors. Implications for further research are addressed.

Carburetor burns: preventable injuries associated with high morbidity and frequent litigation.

We have identified carburetor burns as a significant cause of preventable morbidity, both from long-term functional and cosmetic standpoints. The epidemiology of carburetor burns and our experience are described. All of our patients were male, with a mean age of 35 years. Average burn size was 11.3%. The anatomic distribution of these burns, most often on the dominant hand and on the face, contributes to the morbidity of these burns. This injury has been associated with increasingly frequent litigation. We believe that an active education campaign and the addition of warning labels to car engine compartments would make an impact in decreasing the incidence of carburetor burns.

In vitro evaluation of the stability of ranitidine hydrochloride in total parenteral nutrient mixtures.

The stability of ranitidine hydrochloride in various total parenteral nutrient (TPN) solutions was studied, as well as the effect of ranitidine on the stability of lipid emulsion and amino acids in these solutions. Ranitidine hydrochloride 25 mg/mL was added to each of the following mixtures to make final concentrations of approximately 50 and 100 mg/L: (1) TPN solution containing 4.5% amino acids, 22.7% dextrose, and electrolytes; (2) 10% lipid emulsion; (3) TPN solution containing 3.7% amino acids, 18.5% dextrose, 3.7% lipid emulsion, and electrolytes (all-in-one mixture); and (4) 0.9% sodium chloride injection. Mixtures were tested at room temperature and at 4 degrees C and were either protected from or exposed to fluorescent light. Sampling was done at 0, 12, 24, 36, and 48 hours, and the ranitidine concentration was determined by high-performance liquid chromatography. Samples were also analyzed for lipid particle size distribution and for amino acid content. At 48 hours, the all-in-one mixtures retained 86.0% to 91.4% of the initial ranitidine concentration. With one exception (ranitidine 50 mg/L in 0.9% sodium chloride injection, stored at room temperature and not protected from light), all other solutions retained at least 90% of the initial concentration at 48 hours. No visible changes in color and minimal changes in pH values were noted. There were no important changes in lipid particle-size distribution; 96% of all particles counted from any mixture were smaller than 1.44 microns in diameter at 48 hours. Ranitidine did not have an effect on amino acid concentrations in these mixtures.(ABSTRACT TRUNCATED AT 250 WORDS)