Community health workers' knowledge and practice in relation to pre-eclampsia in Ogun State, Nigeria: an essential bridge to maternal survival.

BACKGROUND: Pre-eclampsia is a leading cause of maternal and fetal morbidity and mortality worldwide. Early detection and treatment have been instrumental in reducing case fatality in high-income countries. To achieve this in a low-income country, like Nigeria, community health workers who man primary health centres must have adequate knowledge and skills to identify and provide emergency care for women with pre-eclampsia. This study aimed to determine community health workers' knowledge and practice in the identification and treatment of pre-eclampsia, as they are essential providers of maternal care services in Nigeria. METHODS: This study was part of a multi-country evaluation of community treatment of pre-eclampsia. Qualitative data were obtained from four Local Government Areas of Ogun State, in south western Nigeria by focus group discussions (N = 15) and in-depth interviews (N = 19). Participants included a variety of community-based health care providers - traditional birth attendants, community health extension workers, nurses and midwives, chief nursing officers, medical officers - and health administrators. Data were transcribed and validated with field notes and analysed with NVivo 10.0. RESULTS: Community-based health care providers proved to be aware that pre-eclampsia was due to the development of hypertension and proteinuria in pregnant women. They had a good understanding of the features of the condition and were capable of identifying women at risk, initiating care, and referring women with this condition. However, some were not comfortable managing the condition because of the limitation in their 'Standing Order'; these guidelines do not explicitly authorize community health extension workers to treat pre-eclampsia in the community. CONCLUSION: Community-based health care providers were capable of identifying and initiating appropriate care for women with pre-eclampsia. These competencies combined with training and equipment availability could improve maternal health in the rural areas. There is a need for regular training and retraining to enable successful task-sharing with these cadres. TRIAL REGISTRATION: NCT01911494 .

Collagen types I and II distribution: a relevant indicator for the functional properties of articular cartilage in immobilised and remobilised rabbit knee joints.

The objective of the present work was to study changes in collagen type I and type II distribution in the articular cartilage of immobilised and remobilised rabbit knee joints. Twenty-four adult male rabbits were divided into three groups. One of the groups was a control group with free movement. The right knee joints of animals of the other two groups were immobilised for 4 weeks, followed by a period of 10 weeks of remobilisation for animals of group 3. Collagen type I and type II in the articular cartilage of tibial medial condyle of the right knee joint were estimated immunohistochemically in all groups. A degenerative process was evident after 4 weeks of immobilisation of rabbit knee joint leading to a partial shift in the density of collagen composition from type II to type I. After a period of 10 weeks of remobilisation, regenerative processes, evidenced by a restoration of collagen type II to normal, proceeded on top of degenerative processes, evidenced by the significantly higher content of collagen type I compared with normal. The present study pointed to the importance of assessment of collagen distribution as a relevant indicator for the functional properties of articular cartilage in immobilised and remobilised joints.

Targeted case finding for hepatitis B using dry blood spot testing in the British-Chinese and South Asian populations of the North-East of England.

Chronic infection with the hepatitis B virus (HBV) is a frequent cause of cirrhosis and liver cancer. Targeted HBV screening is recommended by the Centre for Disease Control (CDC) and Prevention for subjects born in countries with >2% HBV prevalence. However, there are no UK guidelines. Here, we applied the (CDC) recommendations to the British-Chinese and British-South Asian community of North-East (NE) England. British-Chinese and South Asian subjects were invited to attend for HBV education and screening sessions held in community centres. Hepatitis B surface antigen (HBsAg) and hepatitis B core total antibody (HBcAb) were tested with dry blood spot tests. South Asians were also tested for hepatitis C antibody (HCVAb). A total of 1126 subjects (606 Chinese and 520 South Asian) were screened. Sixty-two (5.5%) were HBsAg positive. Ten of these reported a previous diagnosis of HBV. The prevalence of HBsAg positivity was 4.6% when previously diagnosed individuals were excluded. The HBsAg prevalence was significantly higher in the Chinese subjects compared with South Asians (8.7% VS. 1.7% P < 0.001). In Chinese subjects, HBsAg positivity was highest in subjects born in Vietnam (17.4%), followed by China (11%), Hong Kong (7.8%) and the UK (6.7%). Subjects from Pakistan had the highest HBsAg and HCV Ab prevalence in the South Asians (3.1% and 1.8%, respectively). Ten percentage of HBsAg positive patients who had follow-up assessment had active disease requiring antiviral treatment. Undiagnosed HBV infection was above the 2% threshold for screening suggested by the CDC in the British-Chinese and Pakistani community of NE England, which provides evidence for a UK HBV-targeted screening programme.

Correlation of Transient Elastography with Liver Iron Concentration and Serum Ferritin Levels in Patients with Transfusion-Dependent Thalassemia Major from Oman.

Aims: In a longitudinal study, we aimed to assess the correlation between ultrasound transient elastography (TE), serum ferritin (SF), liver iron content (LIC) by magnetic resonance imaging (MRI) T2* along with the fibrosis-4 (FIB-4) score as a screening tool to detect significant liver fibrosis among chronically transfusion-dependent beta-thalassemia (TDT) patients. Methods: The study was conducted at a tertiary health center treating TDT patients. Transient elastography was performed within 3 months of Liver MRI T2* examinations at the radiology department over a median of one-year duration. T-test for independent data or Mann-Whitney U test was used to analyze group differences. Spearman correlation with linear regression analysis was used to evaluate the correlation between TE liver stiffness measurements, Liver MRI T2* values, and SF levels. Results: In this study on 91 patients, the median age (IQR) of the subjects was 33 (9) years, and the median (IQR) body mass index was 23.8 (6.1) kg/m2. Median (IQR) TE by fibroscan, MRI T2*(3T), Liver iron concentration (LIC) by MRI Liver T2*, and SF levels were 6.38 (2.6) kPa, 32.4 (18) milliseconds, 7(9) g/dry wt., and 1881 (2969) ng/mL, respectively. TE measurements correlated with LIC g/dry wt. (rS =0.39, p=0.0001) and with SF level (rS =0.43, P=0.001) but not with MRI T2* values (rS =-0.24; P=0.98). Conclusion: In TDT patients, liver stiffness measured as TE decreased significantly with improved iron overload measured as LIC by MRI and SF levels. However, there was no correlation of TE with the fibrosis-4 (FIB-4) score.

Composition and structure of plant communities in the Moist Temperate Forest Ecosystem of the Hindukush Mountains, Pakistan.

Here, we investigated the relationship between Plant communities and the environment from the moist temperate vegetation of Lakoo mountainous forest District Swat. We sampled data from 162 sampling units (Quadrates) using 1x1m2 for herbs 5x5m2 and shrubs, while 10 x10m2 for trees, systematically considering six elevation gradients between the altitudinal from 1970m to 3095m. We performed statistical analysis like Canonical correspondence analysis (CCA) and TWINSPAN (two-way indicator species analysis) for ecological assessment and clustering of plant communities. To check upon the correlation of species (CR) with topographic and edaphic variables we used statistical software PC-ORD version 7. We recognized 264 species plants belonging to thirty families. We recorded key sampling measurements of density, frequency, and cover for all these species which are vital for community description. The results showed Shannon-Winner,s, and Simpson diversity values as 19.18 and 3.17 respectively. The importance value indexes (IVI) were used to identify the leading and rare species of plant in each community or cluster group. In total we recognized eleven different communities as: Berberis- Abies- Bergeni, Picea - Indigofera- Poa,Abies- Parrotiopsis- Poa, Quercus- Viburnum- Poa, Picea- Salix- Primula, Abies- Viburnum- Poa, Viburnum- Taxus- Poa, Pinus- Viburnum- Lithospermum, Abies-Berberis- carex, Pinus- Viburnum- Poa and Parrotiopsis- Picea- Poa through hierarchical cluster analysis (TWINSPAN). CCA analysis revealed that of all studied edaphic and topographic variables altitude, silt, calcium carbonate, and organic matter were the strongest factors determining plant community diversity and composition in each microclimate of the eleven communities. Visually the vegetation of the forest was dominated by small-sized trees followed by shrubs, and regenerates indicating the stage of secondary regeneration. We found severe human interference in disturbing the existing biodiversity, which requires immediate conservation to ensure sustainable management and utilization of natural resources of the Lalkoo moist temperate forest.

Clinical skills assessment: comparison of student and examiner assessment in an objective structured clinical examination.

BACKGROUND: Learning of basic clinical skills is introduced in Years 1 and 2 of the MBBS Program; the Aga Khan University, Pakistan, through a structured Clinical Skills Teaching program. Acquisition of competence in performing these skills is assessed through use of the Objective Structured Clinical Examination (OSCE). Self-assessment is defined broadly as the involvement of learners in judging whether or not learner-identified standards have been met. OBJECTIVE: Compared Year 2 students' self-assessment of clinical skills with examiners' assessment of performance in an OSCE using a standard rating scale. METHODS: A self-assessment questionnaire was completed by all Year 2 students immediately after the OSCE. Students assessed their performance at three stations, using a performance rating scale. Examiners observed and evaluated the students during history-taking and physical examination using the same rating scale. RESULTS: There were significant positive correlations between examiners' assessments of performance and students' self-assessed ratings in taking consent, obtaining demographic information, history of presenting problems and summarization. Significant differences were observed in pre-procedural skills, comment on prostate, liver palpation percussion and spleen percussion. CONCLUSIONS: Findings highlight the strengths and weaknesses in clinical competence at the end of Year 2 and provide a direction to improve the gaps in the Clinical Skills Teaching program.

Radioimmunoassay of human intestinal goblet cell mucin. Investigation of mucus from different organs and species.

We have developed a double-antibody radioimmunoassay for the quantitative measurement of human goblet cell mucin (GCM) in order to study intestinal mucus in human and other species. The assay used 3H-labeled mucin as the antigen, rabbit antisera, and sheep anti-rabbit IgG antisera as the second antibody. A number of applications of the assay were investigated. A survey of human tissues revealed that mucins of the rectum, colon, and small intestine had identical affinity for the rabbit antibody, whereas lung eyelid conjunctiva, esophagus, and stomach reacted less strongly. GCM concentration ranged from 1.9 to 14 microgram mucin protein/mg tissue protein in the small and large intestine, respectively. The radioimmunoassay was also found to be useful as a marker during the isolation of GCM from human ileal extracts, where it indicated that a 10,000-fold purification had been achieved. Antigenic determinants of the mucin did not rely upon ABH blood group-specific terminal sugars in oligosaccharide chains. A comparison of mucins among various species revealed a partial species specificity of the GCM antibody. Human GCM cross-reacted with dog, monkey, and rabbit mucins, but not with mucins of rat, pig, toad, and oyster. Organ distributions of cross-reactive mucins in rabbit tissues indicated a pattern that was qualitatively similar to that seen in human tissues. Possible implications of these findings for autoimmune diseases are briefly discussed.

Increased body fat percentage and physical inactivity are independent predictors of gestational diabetes mellitus in South Asian women.

OBJECTIVE: This study aims to identify lifestyle predictors of gestational diabetes mellitus (GDM) in South Asian women. Pre-gravid body mass index, body composition, rate of weight gain during pregnancy, physical activity (PA) and dietary intake were studied. DESIGN: Prospective cohort study (n=611) of South Asian women at Aga Khan University Hospital antenatal clinic in Karachi, Pakistan. Weight, height and body fat % were measured and data on PA, diet and socio-economic covariates were collected at baseline. A glucose screen was performed at 29.8+/-2.6 weeks. RESULTS: Using logistic regression analysis for the full cohort, the risk of GDM increased with older maternal age (odds ratio (OR) 1.13, confidence interval (CI) 1.06-1.21), increased body fat % (OR 1.07, CI 1.03-1.13) and the risk was inversely associated with PA (100 kcal) (OR 0.79-0.99, CI 0.89). Using a nested case (n=49) control (n=98) design to study dietary intake, the risk of GDM decreased with increasing protein (% energy) in the diet (OR 0.75, CI 0.60-0.95). CONCLUSIONS: Body fat %, physical inactivity and, possibly, diet quality are important modifiable risk factors for GDM. 2006.

Maternal risk factors associated with low birth weight in Karachi: a case-control study.

To evaluate maternal risk factors associated with low birth weight (LBW) among women aged 15-35 years, we carried out a hospital-based, case-control study on 262 cases (mothers of neonates weighing < or = 2.5 kg) and 262 controls (mothers of neonates weighing > 2.5 kg). Odds of delivering a low-birth-weight baby decreased with increase in maternal haemoglobin [odds ratio (OR): 0.701; 95% confidence interval (CI): 0.62-0.79]. Odds were greater among mothers not using iron supplements during pregnancy (OR: 2.88; 95% CI: 1.83-4.54). Mothers of LBW babies had lower haemoglobin levels before delivery.

Response of first-line antibiotic therapy in patients with febrile neutropenia during treatment of hematological disorders.

Patients with hematological disorders develop febrile neutropenia (FN); most of these events remain undetermined in origin. We performed a prospective study to determine the microbiological characteristics of infections and their response to the first-line antibiotic therapy in FN. The study was conducted at National Institute of Blood Disease and Bone Marrow Transplant. Two-hundred episodes of FN were assessed for the bacterial growth, antimicrobial susceptibility pattern and response to the first-line treatment of FN. All patients were given Ceftazidime and Amikacin Bosch Pharmaceutical (Pvt. Ltd), as first-line antibiotic in FN. Out of 200 episodes we had 108 clinically and microbiologically documented infections. The isolated frequencies for gram negative and gram positive organisms were n = 52 and 49 (48 and 45 %) respectively. Among gram negative micro-organisms, Escherichia coli (E. coli) was isolated in 15 (28.8 %), Klebsiella pneumonae in 4 (7.6 %) and Pseudomonas aeruginosa in 10 (19.2 %) were in highest frequencies. Methicillin sensitive staphylococci emerged as the frequently isolated gram-positive bacteria. Eight-one episodes (45.3 %) responded to the first-line treatment and death reported in 20 cases (10 %). Our study showed almost equal trend of gram positive and gram negative bacteria isolated from patients suffering from neutropenic fever. Empirical use of Ceftazidime and Amikacin as first-line antibiotics was able to cover the infection only in 45.3 % of episodes suffering from FN.

Low-grade B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) of thymus.

This report describes a low-grade B-cell lymphoma of mucosa associated lymphoid tissue (MALT) involving the thymus of a 63-year-old woman with features suggestive of a connective tissue disease. Sections of the thymic lesion and of a lung biopsy performed at the same operation were examined histologically and by immunohistochemistry using the monoclonal antibodies CD45, CD20, CD79a, CD3, CD45RO, and AE1/AE3. Polymerase chain reaction (PCR) for immunoglobulin heavy chain gene rearrangement was also performed. The dense infiltrate of small lymphoid cells intimately admixed with ramifying epithelial elements, some of which had undergone cystic change, closely resembled a thymoma. The lymphoid infiltrate comprised centrocyte-like cells, small lymphocytes, plasma cells, and blasts. Most of the lymphoid cells were immunoreactive with the B-cell markers CD20 and CD79a, and PCR showed clonal immunoglobulin heavy chain gene rearrangement. The lung biopsy showed dense infiltration by small lymphoid cells, morphologically suggestive of lymphoid interstitial pneumonia. However, PCR showed a weak band in the amplification for immunoglobulin heavy chain gene rearrangement, identical to that within the thymus and suggesting either recirculation of cells to accumulated MALT or subhistological lymphoma. MALT lymphoma may rarely involve the thymus, and pathologists should be aware of this to avoid misdiagnosis as a thymoma. Immunohistochemical and/or molecular studies are of value in this regard. MALT lymphomas of the thymus, common with those arising in other organs, may develop in the setting of a connective tissue disease.

Utility of restriction fragment analysis for typing herpes simplex virus amplicons following PCR of targets in the DNA polymerase gene.

We compared the utility of restriction endonuclease cleavage to type herpes simplex virus DNA polymerase gene amplicons from two well established PCR primer sets. Amplicons typed using Ava II had a 96% correlation to type determined by monoclonal antibody staining, while amplicons typed using Drd I had a 72% correlation to type determined by monoclonal antibody staining.

Foreign body in tracheal bronchus simulating bronchogenic cancer.

A foreign body in the bronchial tree may mimic many pathological conditions. We present a case of a 62-year-old patient with a foreign body in the tracheal bronchus simulating bronchogenic cancer. After the removal of the foreign body, there has been a gradual regression of the foreign body induced inflammatory changes. To the best of our knowledge, a similar case has not been reported in the English medical literature.

Bone mass in children with congenital hypothyroidism treated with thyroxine since birth.

To determine whether the large doses of thyroxine treatment early in life adversely affect bone mass, we measured bone mass of 20 congenital hypothyroid (CH) patients (8.4 +/- 2.2 years) who were diagnosed and treated since birth. Starting thyroxine dose and current dose were 8.5 +/- 1.9 micrograms/kg/day and 3.1 + 1.2 micrograms/kg/day respectively. Thyroid function and serum biochemical tests for calcium homeostasis were normal at the time of study. Bone mass was measured by dual energy X-ray absorptiometry. Nine siblings served as controls. The patients' bone mineral density was within the normal range of population controls, and was not different from the sibling controls. The patients also had height-adjusted bone mineral content equal to the expected height-adjusted values in the siblings. Our studies indicate that the large doses of thyroxine therapy for CH do not cause osteopenia in childhood.

Recurrent buccal space abscesses: a complication of Crohn's disease.

Oral features of Crohn's disease include ulcerations, lip fissuring, cobblestone plaques, and mucosal tags. We report the case of a 16-year old male patient with a 3-month history of abdominal pain, diarrhea, and oral ulceration. Clinical examinations revealed established intestinal lesions, a marked cobblestone appearance in the oral cavity, and an unusual pattern of presentation not previously reported in the literature: persistent, recurrent buccal space abscesses.

A study on children's condition thalassemia using neutron activation analysis and other techniques.

In this study, 50 thalassemia patients were tested using dual-energy X-ray absorptiometry (DEXA) and in vivo neutron activation analysis (IVNAA) to determine their bone mineral status. Both techniques were suitable for this purpose. Lower age was found to correspond to lower liver iron content and higher bone mineral content in the normal range. Patients undergoing treatment with transfusion had higher bone mineral content. Osteopenic patients had higher hepatic iron content than those with normal bone status. In the case of DEXA, bone mineral content (BMC) divided by height cubed was found to be a better indicator of bone mineral status than the BMD usually given. Liver density as determined by DEXA correlates well with hepatic iron.

Prevalence of Campylobacter jejuni in eggs and poultry meat in New York State.

The presence of Campylobacter jejuni was tested for but not isolated from any of 276 eggs sampled from 23 egg farms in New York State. The presence of C. jejuni was evaluated in broilers, kosher broilers, spent layers, Peking ducks, and turkeys. Four of five poultry dressing plants tested showed positive growth of C. jejuni on the 25-carcass samples at various stages of processing. Twenty to 100% of live birds sampled contained C. jejuni on the skin but 90 to 100% were contaminated after scalding and defeathering operations from contaminated birds and equipment. A three to four-fold increase in carcass contamination was observed after evisceration. The number of C. jejuni on the carcasses decreased after washing and chilling. The organisms did not survive the salting, rinsing, and chilling operations in a kosher processing plant. Several pieces of equipment, i.e., shackles, eviscerating troughs, and cooling tanks were contaminated with C. jejuni. This study illustrates how C. jejuni may be transmitted from the live bird to the final poultry product.

Effect of an elevated level of carbon dioxide containing atmosphere on the growth of spoilage and pathogenic bacteria at 2, 7, and 13 C.

The effect of 80% CO2 (balance air) on the survival and growth of microorganisms most often associated with spoilage and foodborne disease in poultry carcasses was compared to air at 2, 7, and 13 C. The CO2 atmosphere substantially retarded the growth of the total bacterial load in uninoculated ground chicken meat and parts at all temperatures when compared to air; however, temperature had a larger overall effect than atmosphere. Ground chicken meat and synthetic broth were inoculated (greater than 10(4) cells/ml or g) with Pseudomonas fragi, Salmonella typhimurium, Staphylococcus aureus, or Clostridium sporogenes and the influence of 80% CO2 and incubation temperature studied. With the exception of Cl. sporogenes, 80% CO2 was inhibitory when compared to air at any given temperature. In most cases, CO2 was more inhibitory at 2 C than at 7 or 13 C. The Cl. sporogenes inoculum failed to grow above initial inoculum levels in any combination of temperature and atmosphere, but samples packed in 80% CO2 had higher numbers of colony forming units than air-packaged samples. This study does not indicate that modified atmosphere packaging of refrigerated poultry in elevated CO2 atmospheres increases the microbial hazards when compared to air at the same temperature.

The frequency of salmonellae on duck eggs.

Total plate counts on washed duck eggs from a breeder farm on Long Island were less than 30/shell during the winter (January to February) of 1982. Clean unwashed eggs had counts less than 9 X 10(1)/shell, whereas dirty unwashed eggs had counts as high as 9 X 10(5)/shell. Our results showed that washing with a chlorine sanitizer (under commercial conditions) was highly effective in reducing surface bacterial counts on egg shells. Prolonged storage reduced bacterial counts on clean eggs, but it did not significantly affect loads on dirty eggs. No salmonellae could be detected on shells or in the magma of all eggs examined. In a second trial (March 1982) bacterial loads on washed and clean duck eggs from six different breeder farms were low, ranging from too few to count to 10(2)/shell. A higher proportion of dirty eggs were heavily contaminated with counts ranging from 10(5) to 10(6)/shell, but no salmonellae were detected either on shells or in magma. In the third trial (May 1982) bacterial determinations on eggs from breeder ducks that were not confined followed the pattern of the second trial. However, in this trial Salmonella enteritidis was detected on dirty egg shells in four of six farms. In a fourth trial (May 1983), bacterial loads on washed and nest-clean eggs from the same breeder farms (not confined) ranged between 10(2) to 10(3)/shell and 10(2) to 10(4)/shell, respectively. S. enteritidis and S. badar were recovered from washed, nest clean, and dirty eggs in two of six farms. We conclude that proper egg washing and confinement of duck breeders should minimize the problem of salmonellosis in ducklings.

Characterization of two Escherichia coli isolates associated with poult enteritis and mortality syndrome.

Two colonial types (1 and 2) of Escherichia coli are represented predominantly in cultures isolated from turkey poults with poult enteritis and mortality syndrome (PEMS). Biotype codes determined using two systems (BBL: 36570 and 34560 for colony types 1 and 2, respectively; API-20E: 5144572 and 5144512 for colony types 1 and 2, respectively) clearly establish these organisms as E. coli. These isolates were not clearly divergent from the general profile for E. coli, but colony type 2 differs from colony type 1 with regard to its negative reactions for ornithine decarboxylase and the fermentation of dulcitol, rhamnose, sucrose, and melibiose, suggesting that it is atypical. Colony type 1 is nonserotypable and nonmotile, whereas colony type 2 is serotyped as O136: motile because it has H antigens associated with flagella. Capsular antigens were not found, but thin capsules were seen on cells from both colony types in stained preparations. Cultural morphology was different with colony type 1 having a circular, mucoid, raised morphology and colony type 2 having an irregular, flat, rough morphology. Colony type 1 has a doubling time at 37 C of about 20 min, whereas colony type 2 doubles in 30 min. Furthermore, colony type 1 is a potent colicin producer, but colony type 2 is not a colicin producer. Both E. coli isolates have resistance profiles for multiple antibiotics. Each strain responds to third generation fluoroquinolone antibiotics by changing their biotypes and become resistant after culturing once in their presence. These E. coli are proposed as possible etiological links in the complex series of events that take place in poults susceptible to PEMS.