Efficacy of antimicrobial treatment in non-dysenteric persistent diarrhoea in a community setting

Objectives : To determine the efficacy of antimicrobial treatment in non-dysenteric persistent diarrhoea in a community setting. Methods : In this double-blind field trial, 156 children aged 4 36 months with persistent diarrhoea not associated with Giardia lamblia infestation seeking treatment in a community outpatient clinic, were randomized to receive a combination of nalidixic acid and metronidazole, metronidazole alone, or placebo for 7 days. Results : In comparison with placebo, metronidazole treatment did not result in a significant reduction in the mean post-enrolment diarrhoeal duration and stool frequency, increase in the proportion of patients recovered by days 3, 5 and 7 of treatment, and increase in weight gain at days 7 and 14. Comparing the combination of nalidixic acid and metronidazole with metronidazole alone, 17.5% more children treated with the combination recovered by day 3 of treatment ( p = 0.08) and the mean stool frequency ascertained on day 7 for the previous 24 h was 26.8% less in them ( p = 0.05). The weight gains at days 7 and 14 were similar in the two groups. Conclusions : These findings indicate that metronidazole offers no therapeutic benefit in persistent diarrhoea not associated with Giardia lamblia and nalidixic acid has only a modest clinical benefit, which is not substantial enough to warrant its routine use.     

Retrograde pulmonary vein wedge angiography: A new technique

A new technique of pulmonary vein wedge angiography to delineate pulmonary artery anatomy is described. Conventional pulmonary vein wedge angiography requires an interatrial communication—natural or created by a transseptal puncture. In retrograde pulmonary vein wedge angiography, the left atrium and pulmonary veins are entered from arterial route using a specially designed catheter. This technique can be specially utilized for patients in whom there is no interatrial communication.     

Synchronous mucosa-associated lymphoid tissue (MALT) lymphomas involving bilateral orbits and breasts: a rare clinical entity

Primary orbital and primary breast lymphomas comprise very small subgroups of extranodal lymphomas. Clinical presentation at both these sites together is extremely rare. We describe a case of bilateral orbital and bilateral breast mucosa-associated lymphoid tissue (MALT) lymphomas with bilateral pre-auricular lymph nodal metastasis. The case history, staging and management for this unusual entity are discussed.     

Polio eradication in India: current status

India has reached the final stage of polio eradication. The polio partnership in India, under the leadership of the Government of India, mounted tremendous response to the outbreak. The progress since 2003 is the most significant in the history of polio eradication in India. Surveillance sensitivity was increased to reach the goal for polio eradication. Since nearly all polio cases now occurring in India are caused by type 1 poliovirus in children, monovalent oral polio vaccine type 1 (mOPV1) was introduced in select high-risk districts of UP, Bihar and Mumbai-Thane during the April and May 2005 National Immunisation Days and the June and August 2005 in 6 sub-national immunisation rounds. Strategies were also being implemented to improve the impact of supplementary immunisation activities in the high-risk areas. As a result of supplementary immunisation activities targeted using surveillance data, India has made striking progress towards polio eradication.     

Use of multiple opportunities for improving feeding practices in under-twos within child health programmes

Objectives: In a community randomized trial, we aimed to promoteexclusive breastfeeding and appropriate complementary feedingpractices in under-twos to ascertain the feasibility of usingavailable channels for nutrition counselling, their relativeperformance and the relationship between intensity of counsellingand behaviour change. We also assessed whether using multipleopportunities to impart nutrition education adversely affectedroutine activities. Methods: We conducted a community randomized, controlled effectivenesstrial in rural Haryana, India, with four intervention and fourcontrol communities. We trained health and nutrition workersin the intervention communities to counsel mothers at multiplecontacts on breastfeeding exclusively for 6 months and on appropriatecomplementary feeding practices thereafter. The interventionwas not just training health and nutrition workers in counsellingbut included community and health worker mobilization. Findings: In the intervention group, about 32% of caregiverswere counselled by traditional birth attendants at birth. Themost frequent sources of counselling from birth to 3 monthswere immunization sessions (45.1%) and home visits (32.1%),followed closely by weighing sessions (25.5%); from 7 to 12months, home visits (42.6%) became more important than the othertwo. An increase in the number of channels through which caregiverswere counselled was positively associated with exclusive breastfeedingprevalence at 3 months (p = 0.002), consumption of milk/cerealgruel or mix use at 9 months (p = 0.004) and 18 months (p =0.003), undiluted milk at 9 months (p<0.0001) and 24 hournon-breast-milk energy intakes at 18 months (p = 0.023), aftercontrolling for potential confounding factors. Interventionareas, compared with the control, had higher coverage for vitaminA (45% vs. 11.5%) and iron folic acid (45% vs. 0.4%) supplementation. Conclusions: Using multiple available opportunities and workersfor counselling caregivers was feasible, resulted in high coverageand impact, and instead of disrupting ongoing services, resultedin their improvement.     

Biosynthesis and periplasmic segregation of human proinsulin in Escherichia coli.

A plasmid containing human preproinsulin cDNA inserted into the endonuclease Pst I site of the ampicillinase gene of plasmid pBR322 was modified by excision of large portions of the ampicillinase-coding region to produce a variety of gene fusion combinations, many of which generated proteins detectable with antisera to insulin or human C peptide. In one case a perfect hybrid of the NH2-terminal half of the leader sequence of ampicillinase (residues -23 to -12) with the human preproinsulin prepeptide beginning at residue -13 was formed; the result was the synthesis and secretion of human proinsulin into the periplasmic space. We have characterized this protein immunologically and also by labeling it biosynthetically or by iodination followed by immunoprecipitation and automated amino acid sequence analysis. It contains the A and B chain regions of insulin as well as specific human C peptide immunodeterminants and is convertible to an insulin-like component by tryptic digestion. These results demonstrate that human proinsulin can be produced by bacteria and that this biosynthetic approach should prove feasible for the production of adequate amounts of human proinsulin for a variety of clinical studies and human insulin for therapeutic purposes.     

Neonatal survival: a call for action

To achieve the Millennium Development Goal for child survival (MDG-4), neonatal deaths need to be prevented. Previous papers in this series have presented the size of the problem, discussed cost-effective interventions, and outlined a systematic approach to overcoming health-system constraints to scaling up. We address issues related to improving neonatal survival. Countries should not wait to initiate action. Success is possible in low-income countries and without highly developed technology. Effective, low-cost interventions exist, but are not present in programmes. Specific efforts are needed by safe motherhood and child survival programmes. Improved availability of skilled care during childbirth and family/community-based care through postnatal home visits will benefit mothers and their newborn babies. Incorporation of management of neonatal illness into the integrated management of childhood illness initiative (IMCI) will improve child survival. Engagement of the community and promotion of demand for care are crucial. To halve neonatal mortality between 2000 and 2015 should be one of the targets of MDG-4. Development, implementation, and monitoring of national action plans for neonatal survival is a priority. We estimate the running costs of the selected packages at 90% coverage in the 75 countries with the highest mortality rates to be US4.1 billion dollars a year, in addition to current expenditures of 2.0 billion dollars. About 30% of this money would be for interventions that have specific benefit for the newborn child; the remaining 70% will also benefit mothers and older children, and substantially reduce rates of stillbirths. The cost per neonatal death averted is estimated at 2100 dollars (range 1700-3100 dollars). Maternal, neonatal, and child health receive little funding relative to the large numbers of deaths. International donors and leaders of developing countries should be held accountable for meeting their commitments and increasing resources.