Lead-associated deficits in stature,mental ability and behaviour in children in Karachi

This study was conducted to evaluate the cumulative and steady-state lead burden in children from Karachi, an area of high lead exposure, and to assess the degree of damage to physical growth and mental ability related to lead exposure. A cross-sectional survey was conducted in seven primary schools from around Karachi. Shed primary teeth and blood samples were collected from students of grades I to III (age range 6-10 years) and were analysed for lead by atomic absorption spectrophotometry. Haemoglobin concentration, height, weight and head circumference were measured. IQ was estimated using Raven's Standard Progressive Matrices. Classroom behaviour was rated by teachers and school performance was estimated from the percentage mark in a school examination taken just before the date of the IQ test. Complete data were available for 138 children. Over 80% of children had lead levels above the safety limit set by the United States Centers for Disease Control and Prevention. The blood lead levels in boys did not differ significantly from that in girls. Significant differences were observed between the schools. Univariate analysis showed negative association of blood lead with haemoglobin, IQ and height. Tooth lead was negatively associated with height, classroom behaviour and performance. When adjusted for other confounding variables, blood lead was negatively associated with haemoglobin and IQ, whereas tooth lead was negatively associated only with classroom behaviour. Height was negatively associated with blood or tooth lead. These results were further supported when the upper and lower quintiles for blood or tooth lead were compared. Tooth lead level was not a better marker of lead poisoning than blood lead level in our study population. These data demonstrate the association of increased lead with impaired learning and adverse behaviour in Karachi children and call for strict government regulations to limit environmental lead burden.     

Two-stage palatoplasty using a modified Furlow procedure

A two-stage palatal repair using a modification of Furlow palatoplasty is presented. The authors investigate the speech outcome, fistula formation and maxillary growth. In a prospective, successive cohort study, 40 nonsyndromic patients with wide cleft palate were operated on between March 2001 and June 2006 by a single surgeon. 10 patients in the first cohort underwent a Furlow palatoplasty (control group). In 30 patients in the second cohort a unilateral myomucosal cheek flap was used in combination with a modified Furlow palatoplasty (study group). The hard palate was closed in both groups 9–12 months later. The Bzoch speech quality score was superior in the study group, and the hypernasality was significantly reduced in the study group. Overall fistula formation was 0%. At the time of hard palate reconstruction palatal cleft width was significantly reduced. Relative short-term follow up of maxillary growth was excellent. There were no postoperative haematomas, infections, or episodes of airway obstruction. This technique is particularly encouraging, because of better speech outcome, absence of raw surfaces on the soft palate, no fistula formation, and good maxillary growth. Further follow-up is necessary to determine the long-term effects on facial development.     

What Predicts Clinician Dropout from State-Sponsored Managing and Adapting Practice Training

Dropouts from system-wide evidence-based practice trainings are high; yet there are few studies on what predicts dropouts. This study examined multilevel predictors of clinician dropout from a statewide training on the Managing and Adapting Practice program. Extra-organizational structural variables, intra-organizational variables and clinician variables were examined. Using multivariable logistic regression analysis, state administrative data and prospectively collected clinician participation data were used to predict dropout. Two characteristics were predictive: younger clinicians and those practicing in upstate-rural areas compared to downstate-urban areas were less likely to drop out from training. Implications for research and policy are described.     

Rhabdomyosarcoma arising in a giant congenital melanocytic nevus

We report the case of a 6-week-old girl who presented with a pedunculated embryonal rhabdomyosarcoma arising in a giant congenital melanocytic nevus (GCMN) on her lower back. There was no associated leptomeningeal involvement. The patient underwent surgical resection of the rhabdomyosarcoma at age 2 months, with subsequent chemotherapy consisting of actinomycin D and vincristine. No recurrences or metastases of tumor have been noted at 5 months of age.     

Is folklore use of Euphorbia helioscopia devoid of toxic effects?

Objective: To evaluate acute toxic effects of Euphorbia helioscopia in order to assure the safety and usefulness of herbal remedy.

Materials and methods: The Organization for Economic Cooperation and Development (OECD) for chemical testing guidelines No. 425 for acute oral toxicity testing were followed in this study. Mice were divided into three groups (n?=?5). Group I served as control. Groups II and III were administered methanol extract of E. helioscopia leaves and latex orally at dose of 2000?mg/kg, respectively. Then, all the animals were observed for two weeks. Blood sampling was done by cardiac puncture after 14 days from each group for biochemical analysis. Histopathology was performed to find out any microscopic lesion in vital organs.

Results and discussion: LD₅₀ was found greater than 2000?mg/kg. There was decrease in cholesterol, triglycerides, LDL and VLDL levels of latex and leaves with methanol extract-treated animals, with respect to control indicating plant’s hypolipidemic effect. On macroscopic examination, no lesions were found on vital organs, such as liver, heart and kidney; and normal architecture was observed on microscopic examination.

Conclusion: On the basis of results, it was concluded that methanol extract of E. helioscopia leaves and latex were devoid of toxic effects in acute toxicity study.     

Leflunomide in Pakistani patients with rheumatoid arthritis: prospective study in daily rheumatology practice

Introduction: Leflunomide is a disease‐modifying anti‐rheumatic drug (DMARD) for rheumatoid arthritis (RA). It has been widely studied in the West but there is no available local Pakistani data. Objective: To evaluate the efficacy and safety profile of leflunomide in Pakistani patients with RA, either alone or in combination with methotrexate. Materials and methods: A prospective, non‐comparator, open‐label study in a setting of ‘care as usual’ was performed. In this study, 63 consecutive RA patients on leflunomide were enrolled. Leflunomide dose was started with full loading in 5 (8%), half loading in 39 (62%) and without loading in 19 (30%) patients. Methotrexate was also used in 20 (32%) patients. Primary end‐point was 20% improvement in American College of Rheumatology response criteria (ACR‐20). Safety was assessed by adverse events and abnormalities in laboratory parameters. Results: Out of 63 patients, 54 (85.7%) were female. Mean age was 46 ± 12.6 years. Mean disease duration was 5.1 ± 4.5 years. Fifty‐two (86.6%) patients achieved ACR‐20 response at 6 months; 32 (53%) achieved ACR‐50 response at 6 months; 20% experienced at least one adverse event, which resolved by reducing leflunomide dose. Only seven (11%) had raised liver enzymes from baseline. Conclusion: This prospective study conducted in the setting of a daily rheumatology practice shows that leflunomide is an effective and safe DMARD in treatment of RA in Pakistani patients.     

Clinical Isolates of Salmonella enterica Serovar Agona Producing NDM-1 Metallo-β-Lactamase: First Report from Pakistan

We report two cases of infantile diarrhea due to multidrug-resistant, NDM-1 metallo-β-lactamase-producing Salmonella enterica serovar Agona from Pakistan. This study alerts toward possible risk of NDM-1 transmission to enteric fever pathogens and encourages microbiologists to consider active screening of carbapenem resistance in nontyphoidal Salmonella isolates.     

Inflammatory actinic keratoses secondary to systemic chemotherapy

Traditionally, systemic 5-fluorouracil has been associated with a reaction that produces inflammation of preexisting and subclinical actinic keratoses (AKs). We report a case of an inflammatory reaction occurring in AKs secondary to the use of doxorubicin. The cutaneous reaction was successfully managed with the application of high-potency topical steroids over the body and with pain management. When the doxorubicin was discontinued and another agent (paclitaxel) was instituted, the cutaneous reaction gradually diminished.