Hereditary haemorrhagic telangiectasia: a cause of preventable morbidity and mortality

Hereditary haemorrhagic telangiectasia (HHT) is an autosomal dominant condition whose effects are mediated through deficient blood vessel formation and regeneration, with multisystem involvement. Patients are usually aware of resulting skin telangiectasia and epistaxis, but are also exposed to dangers posed by occult vascular malformations in other organs. About 15–35% of HHT patients have pulmonary AVMs (PAVMs), 10% have cerebral AVMs (CAVMs), 25–33% suffer significant GI blood loss from GI tract telangiectasia, and an unknown but high percentage have liver involvement. In total, 10% of affected individuals die prematurely or suffer major disability from HHT, largely because of bleeding from CAVMs and PAVMs, or paradoxical embolization through PAVMs. Screening for and early intervention to treat occult PAVMs and CAVMs can largely eliminate these risks, and should be undertaken in a specialist centre. The National HHT Center in The Mercy University Hospital in Cork is the referral centre for HHT screening in Ireland.     

Environmental tobacco smoke exposure among police officers in Hong Kong

CONTEXT: Few epidemiological studies have examined the relationship between chronic respiratory symptoms and exposure to environmental tobacco smoke (ETS) at work in adults, and none have shown clear dose-response relationships. OBJECTIVE: To examine the respiratory effects of ETS exposure at home and at work among never-smoking adults. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional, self-administered questionnaire survey conducted in December 1995 and January 1996 among 4468 male and 728 female police officers in Hong Kong who were never-smokers. MAIN OUTCOME MEASURES: Respiratory symptoms and physician consultation in the previous 14 days for such symptoms by presence and amount of ETS exposure at work. RESULTS: Eighty percent of both men and women reported ETS exposure at work. Significant odds ratios (ORs) for respiratory symptoms were found among men with ETS exposure at work (for any respiratory symptoms, difference in absolute rate, 20.4%; OR, 2.33; 95% confidence interval [CI], 1.97-2.75; attributable risk, 57%) and physician consultation (difference in absolute rate, 4.5%; OR, 1.30; 95% CI, 1. 05-1.61; attributable risk, 23%). Trends were similar among women for any respiratory symptoms (difference in absolute rate, 15.4%; OR, 1.63; 95% CI, 1.04-2.56; attributable risk, 39%) and for physician consultation (difference in absolute rates, 2.8%; OR, 1.45; 95% CI, 0.87-2.41; attributable risk, 31%). Positive dose-response relationships with number of coworkers smoking nearby and amount of ETS exposure in the work place were found. CONCLUSIONS: This study provides further evidence of the serious health hazards associated with ETS exposure at work. The findings support a ban on smoking in the workplace to protect all workers in both developed and developing countries. JAMA. 2000;284:756-763     

Oklahoma and the issue of tobacco

Tobacco use, particularly cigarette smoking, continues to be the leading cause of preventable morbidity and mortality in the United States. An important public health issue, this has been the focus of much study. Several organizations have issued statements and recommendations for handling this issue. Reducing tobacco use is a key component of Healthy People 2010, the national action plan for improving the health of all Americans. The Surgeon General, Agency for Healthcare Research and Quality (AHRQ) and the U.S. Preventive Services Task Force (USPSTF) have put forth valuable guidelines concerning preventive services in the primary care setting, and programs such as Putting Prevention into Practice (PPIP) and state based initiatives have aimed to implement them. States that have taken these messages to heart and acted upon them to fully implement these preventive measures and interventions have had significant success, most notably Oregon, California and Massachusetts. In less than a decade, the Massachusetts Tobacco Control Program has evolved into one of the leading public health initiatives of our time. Perhaps by learning from their successes we can bring about a similar change in the state of Oklahoma.     

Passive exposure to tobacco smoke: saliva cotinine concentrations in a representative population sample of non-smoking schoolchildren

Saliva cotinine concentrations in 569 non-smoking schoolchildren were strongly related to the smoking habits of their parents. When neither parent smoked the mean concentration was 0.44 ng/ml, rising to 3.38 ng/ml when both parents were cigarette smokers. Mothers' smoking had a stronger influence than did fathers' (p less than 0.01). In addition, there was a small independent effect of number of siblings who smoked (p less than 0.01). The dose of nicotine received from fathers' smoking was estimated as equivalent to the active smoking of 30 cigarettes a year, that from mothers' smoking as equivalent to smoking 50 cigarettes a year, and that from both parents smoking as equivalent to smoking 80 cigarettes a year. This unsolicited burden may be prolonged throughout childhood and poses a definite risk to health.     

环境烟草烟雾暴露对小鼠脑区神经递质表达的影响

目的 通过观察小鼠脑部神经递质的变化,初步探讨环境烟草烟雾(ETS)成分对小鼠神经系统的影响.方法 在染毒实验台内对小鼠染毒,染毒8周造模后进行小鼠脑区定位,免疫组织学方法和图像分析观察脑区神经递质表达的变化结果 (1)GABA在小鼠大脑皮层、海马部位的表达:ETS暴露组阳性细胞数量明显减少(大脑皮层:0.25±0.10;海马:0.19±0.07)(P＜0.05).(2)nAChR在大脑皮层的表达:ETS吸入组阳性表达明显增加(0.31±0.10)(P＜0.05).(3)NMDAR在小鼠大脑皮层、纹状体皮质的表达:ETS吸入组(0.31±0.08,0.35±0.11)、尼古丁(Nic)吸入组阳性表达增加明显(P＜0.05).结论 ETS、Nic可导致大脑皮层、下丘脑等部位神经递质及受体表达的变化.

Abstract：

Objective To explore the mechanism of the influence on mice brain of environmental tobacco smoke. Methods After the mice were placed into the bench for 8 weeks, the region of the mice brain was localized and the expression of neurotransmitters and neurotransmitters receptors were detected by immunohistochernistry.Results ( 1 ) The expression of GABA in the mice cerebral cortex ( CC ) ( 0. 25 ± 0. 06 ) and the hippocampus (Hip) (0. 19 ± 0. 07 ) were much higher in the ETS-exposed group than that in the control group(P＜ 0. 05 ). (2)The expression of nAChR on CC(0. 31 ±0. 10) was much more in the ETS-exposed group than that in control group(P＜0.05). (3) The expression of NMDAR( Glu receptors) on the CC and striate cortex were much higher in the ETS-exposed group(0.32 ±0. 10,0.38 ±0. 14), NIC-inhaling group(0.31 ±0. 08,0.31 ± 0. 11 ) than that in control group(P＜0. 05 ). Conclusions Long-term ETS-exposed and NiC-exposed environment could change the expression of neurotransmitter and its receptors.     

环境烟草烟雾与从不吸烟的中国妇女的死亡率：前瞻性队列研究

目的：评价源自丈夫、工作场所以及生命早期家庭成员的环境烟草烟雾暴露与中国妇女全死因、恶性肿瘤或心血管疾病死亡率的关系。设计：中国上海正在进行的前瞻性队列研究。参加人员：72829名从不吸烟妇女中有65180人提供了其丈夫的吸烟资料，有66520人提供了源自工作场所和生命早期家庭成员的烟草烟雾暴露资料。主要的评价结果指标：全死因死亡率以及恶性肿瘤、心血管疾病死亡专率。按暴露状况分层的累积死亡率以及风险比。结果：源自丈夫的烟草烟雾暴露（主要是现时暴露）与全死因死亡率增加有显著联系，风险比（HR）为1．15，95％可信区间为1.01～1．31，与心血管疾病死亡率增加也有联系（1、37，1．06～1．78）。源自工作场所的烟草烟雾暴露与恶性肿瘤死亡率增加有联系（1、19，0．94～1．50），特别是肺癌（1．79，1．09～2．93）。生命早期暴露与心血管疾病死亡率增加有联系（1．26，0．94～1．69）。结论：在中国妇女中环境烟草烟雾暴露与全死因死亡率以及肺癌和心血管疾病死亡率的中等度增加有关。     

Postpartum haemorrhage: a cause of maternal morbidity

To identify and analyse the risk factors associated with postpartum haemorrhage (PPH) and assess their impact on the maternal morbidity, a prospective observational study was carried out over a period of one year in a tertiary level referral institute in Kolkata, West Bengal, India. All the cases of PPH were identified and studied. Data analyses were done using Chi-square test. Out of 210 cases of maternal morbidity, 79 (37.6%) were found to have PPH as the causative factor. Uterine atonicity was found to be the main cause leading to 45 cases (56.9%) of PPH. With respect to the mode of delivery severe PPH was found in 34.3% of vaginally and 60% of operatively delivered patients which had statistical significance. More number of severe PPH cases, 17/31 (54.8%), had delivered outside the medical college. Here comes the role of 24-hour quality emergency obstetric care (EMOC), active management of 3rd stage of labour and early referral to the higher centre. The case fatality rate of PPH during the study period was 7.5%. This finding is quite close to the observation made in a North Indian tertiary hospital based study. In order to reduce maternal morbidity and thereby indirectly maternal mortality and to improve the overall maternal health, prevention and control of PPH can play a significant role. An integrated approach at all levels of healthcare delivery system, active management of labour and efficient emergency obstetric care will help in controlling the PPH.     

Exposure time and ventricular remodeling induced by tobacco smoke exposure in rats.

BACKGROUND: We investigated the effects of length of exposure to tobacco smoke on the cardiac remodeling process induced by exposure to cigarette smoke in rats. MATERIAL/METHODS: Rats were separated into 4 groups: nonsmoking (NS)2 (n=25; control animals not exposed to tobacco smoke for 2 months), smoking (S)2 (n=22; rats exposed to smoke from 40 cigarettes/d for 2 months), NS6 (n=18; control animals not exposed to tobacco smoke for 6 months), and S6 (n=25; rats exposed to smoke from 40 cigarettes/d for 6 months). All animals underwent echocardiographic, isolated heart, and morphometric studies. Data were analyzed with a 2-way analysis of variance. RESULTS: No interaction among the variables was found; this suggests that length of exposure to tobacco smoke did not influence the effects of exposure to smoke. Values for left ventricular diastolic diameter/body weight and left atrium/body weight were higher (p=0.023 and p=0.001, respectively) in smoking (S2 and S6) than in nonsmoking animals (NS2 and NS6). Left ventricular mass index was higher (p=0.048) in smoking than in nonsmoking animals. In the isovolumetrically beating ventricle, peak systolic pressure was higher (p=0.034) in smoking than in nonsmoking animals. Significantly higher values were found for left ventricular weight (p=0.017) and right ventricular weight (p=0.001) adjusted for body weight in smoking as opposed to nonsmoking animals. Systolic pressure was higher (p=0.001) in smoking (128+/-14 mm Hg) than in nonsmoking animals (112+/-11 mm Hg). CONCLUSIONS: Length of exposure to cigarette smoke did not influence cardiac remodeling caused by exposure to smoke in rats.     

Glucose-6-phosphate dehydrogenase deficiency: a preventable cause of mental retardation

Over two years cord blood from 27 879 babies was screened for glucose-6-phosphate dehydrogenase (G6PD) deficiency. The overall incidence was 3.1% in boys and 1.6% in girls. Sixty nine babies had severe jaundice (bilirubin concentration greater than 380 mmol/l (20 mg/100 ml], and exchange transfusion was performed. Parents were given written and verbal instructions to avoid herbs and drugs that trigger kernicterus, which reduced the incidence of kernicterus and thereby prevented mental retardation. G6PD deficiency is common in all three ethnic groups (Malays, Chinese, and Indians) in Malaysia and screening is recommended.     

Autonomic neuropathy--a preventable cause of death in tetanus

A patient with autonomic neuropathy complicating tetanus is presented. The recognition and management of this potentially reversible complication is discussed.     

Caesarean section in Malawi: preventable factors in maternal and perinatal mortality

Objectives

To examine factors that may influence maternal and perinatal mortality associated with caesarean section in an African country.

Design

A prospective observational study, conducted between January 1998 and June 2000, of 8070 caesarean sections.

Setting

25 district and 2 central hospitals in Malawi.Main outcome measures. Association between hospital type, ward or operative care, training of surgical and anaesthesia personnel, preoperative complications, method of anaesthesia, blood loss and anaesthetic technique on maternal and perinatal mortality.

Results

Questionnaires were returned for 5236 caesarean sections in district and 2834 in central hospitals. 95% were emergencies, 65% for obstructed labour. Pre-operative haemorrhagic shock was present in 7.6% of women, anaemia in 6.2% and ruptured uterus in 4.1%. Previous caesarean section did not appear to predispose to ruptured uterus. There were 85 maternal deaths (1.05% mortality), 65 of which occurred postoperatively on the wards. Maternal mortality was increased with ruptured uterus (adjusted odds ratio 3.9, 95% CI 2.3–6.5), little anaesthetic training (2.3, 1.3 to 4.1) and blood loss requiring transfusion (19.3, 9–41). In mothers without preoperative haemorrhage spinal anaesthesia was associated with lower maternal mortality than general anaesthesia (0.23, 0.1–0.7). Perinatal mortality was 11.2% overall, and was significantly associated with ruptured uterus, halothane and ketamine anaesthesia.

Conclusion

Maternal and perinatal mortality rates among women undergoing caesarean section in Malawi are high. Improving resuscitation in postoperative wards might reduce maternal mortality. Blood loss and pre-operative complications are both strongly associated with mortality. Spinal anaesthesia was associated with good outcome.