Cutaneous gangrene with hyperparathyroidism

Cutaneous gangrene complicating renal failure with hyperparathyroidism is a rare but recognized association^1–3 the aetiology of which remains unknown. In a few of the described cases healing of the gangrenous areas has been reported following removal of a parathyroid adenoma^1,2 and this case report illustrates this point. We have also performed clotting studies in an attempt to elucidate any factors which might explain the fibrin clots observed historically and the subsequently observed cutaneous necrosis.     

Public-private partnership in water supply and sanitation in Sub-Saharan Africa

Purely public water supply systems are characterized by highcosts, insufficient supplies and chronic deficits that are coveredby central government transfers. The private water supply programmein Abidjan has not met its coverage targets either, but thesystem has remained financially solvent and fostered a rapidgrowth in capacity through the informal sector. The materialreviewed here and the experience of developing country watersystems in general support several conclusions. (1) Water vendingis common in developing countries, which suggests that chargingfor water is not culturally unacceptable. Demand for wastewaterservices is low, but surcharges could be imposed on water usageto cover some sanitation costs. (2) Incentives are criticalto sound management of water supply and sanitation services.They are typically part of the structure of private firms, butare rare in publicly run systems. (3) The private sector's rolein the provision of water supply and sanitation can be extensive.Regulation of private activity and quality control by publicauthorities is essential to maintain competition and ensureproper and fair operation. (4) Public efforts to supply watercan be supplemented by a government-regulated, parallel systemto increase the amount of water available. Normally these systemsinvolve trucked water, but private sales outlets with pipe infrastructureshould be encouraged where feasible. (5) Even where the publicsector decides to control and operate the water supply and sanitationsystem, some partnership with the private sector is possiblethrough contracting out specific tasks such as billing, metering,maintenance of various components or tracking water losses.Finally, the supply of water is an ideal activity for a public-privatepartnership. Both sectors have comparative advantages that arebest applied in conjunction with the other.     

Radiofrequency Catheter Ablation of an Atriofascicular Pathway During Atrial Fibrillation:

Atriofascicular Ablation During Fibrillation. Introduction: A male patient with an atriofascicular pathway underwent catheter ablation of the atriofascicular pathway during atrial fibrillation.
Methods and Results: The patient had preexcited atrial fibrillation both clinically and repeatedly during electrophysioiogic study. A preexcited tachycardia with a 1:1 AV relationship and regular RR intervals was also induced. Catheter ablation of the atriofascicular pathway could only be performed during persistent atrial fibrillation, based on mapping of the pathway's insertion into the right bundle branch. Following successful ablation and cardioversion to sinus rhythm, a regular QRS tachycardia (atrioventricular [AV] nodal reentry) having (he same rate, atrial activation sequence, and His-atrial time as the regular preexcited tachycardia noted preablation was initiated. An AV nodal slow pathway modification eliminated this tachycardia. Neither atrial fibrillation nor AV nodal reentry has recurred on follow-up.
Conclusion: This is the first report of atriofascicular mapping and ablation performed exclusively during atrial fibrillation and illustrates the utility of mapping the pathway's ventricular insertion. Other unusual features ("bystander" pathway activation during AV nodal reentry, possible role of the pathway in genesis of atrial fibrillation) are discussed.