Evaluation of a primary health care programme in The Gambia. II. Its impact on mortality and morbidity in young children

Mortality and morbidity in children under 5 years of age were measured in 41 villages and hamlets in a rural area of The Gambia for a 1-year period before and for a 3-year period after the introduction of a primary health care (PHC) programme into 15 of the larger villages in the area. Both infant mortality and child mortality rates fell during the post-intervention period but declines were similar in PHC and in non-PHC villages suggesting that factors such as an up-grading of the Farafenni dispensary, improvements in transport and the survey itself may have played an important part in bringing about these changes. Measurements of morbidity showed a lower prevalence of diarrhoea, vomiting or severe cough in PHC villages after the introduction of the PHC programme. Introduction of the PHC programme had no significant effect on nutritional status or on vaccine coverage. Significant improvements in the health of children in the Farafenni study area have taken place during the past 5 years but the PHC programme is probably only one of the factors that have brought about these changes.     

A randomised prospective study of split skin graft donor site dressings: AWBAT-D™ vs. Duoderm®

Objective

To assess patient comfort and wound-healing efficacy of a new, purpose-designed biosynthetic material (AWBAT-D™) in the healing of split-skin graft donor sites in comparison with our standard dressing, Duoderm^®.

Materials and methods

We conducted a prospective randomised controlled trial of donor site dressings, comparing AWBAT-D™ with our standard dressing, Duoderm^®. Patients were randomly allocated to have their donor site dressed with one of these materials. Outcome measures included pain scores at rest and during dressing changes, time to re-epithelialisation, time to discharge, scarring and infection. Results were assessed for significance using the Mann–Whitney U-test (non-parametric data) and the Chi-Square test (parametric data).

Results

Fourteen patients were recruited with 8 donor sites in each group. The mean pain scores at rest and during dressing changes were not found to be significantly different between the two groups (P = 0.99 and P = 0.90 respectively). The median time to re-epithelialisation was shorter in the Duoderm^® group at 11 days compared to 17 days in the AWBAT-D™ group (P = 0.007). The median time to discharge was not significantly different (P = 0.38). No infection or scarring has been observed.

Conclusions

Based on these early results, AWBAT-D™ appears to have slower donor site healing and does not provide significant improvements in postoperative pain or discharge time compared to Duoderm^®. There is no evidence at this stage that our standard donor site dressing should be changed.     

Pathomechanism and Management of Stroke in COVID-19: Review of Immunopathogenesis,Coagulopathy, Endothelial Dysfunction,and Downregulation of ACE2

Coronavirus disease 2019 (COVID-19) can reportedly manifest as an acute stroke, with most cases presenting as large vessel ischemic stroke in patients with or without comorbidities. The exact pathomechanism of stroke in COVID-19 remains ambiguous. The findings of previous studies indicate that the most likely underlying mechanisms are cerebrovascular pathological conditions following viral infection, inflammation-induced endothelial dysfunction, and hypercoagulability. Acute endothelial damage due to inflammation triggers a coagulation cascade, thrombosis propagation, and destabilization of atherosclerosis plaques, leading to large-vessel occlusion and plaque ulceration with concomitant thromboemboli, and manifests as ischemic stroke. Another possible mechanism is the downregulation of angiotensin-converting enzyme 2 as the target action of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). Acute stroke management protocols need to be modified during the COVID-19 pandemic in order to adequately manage stroke patients with COVID-19.     

The role of premorbid personality and cognitive factors in awareness of illness,memory, and behavioural functioning in Alzheimer's disease

Introduction. Research has suggested an association between personality factors and awareness in patients with dementia, yet valid measurement of premorbid personality is problematic. The present study aimed to better reveal the relationship between premorbid personality and awareness by using improved methodology. Moreover, the study aims to contrast the strength of the relationship of premorbid personality and awareness with that of cognitive factors.

Methods. Awareness of illness, symptoms, mnemonic and behavioural impairments, and treatment compliance were measured in 27 patients with mild-to-moderate Alzheimer's disease (AD) diagnosed by standard criteria for probable AD. Participant premorbid personality was measured using average retrospective Neuroticism-Extroversion-Openness Inventory (NEO-FFI) scores from two informants. Correlations were performed to investigate the relationship between awareness and personality dimensions, as well as measures of cognitive style, neuropsychological function, mood, carer burden, and sociodemographic factors.

Results. There was little relationship between awareness and personality scores, but modest associations between awareness and mood, age, and age of onset of first symptoms. Awareness of memory was related to memory functioning. Increased carer burden was associated with lack of awareness of cognitive-behavioural deficits but there were only few and weak associations between awareness and measures of cognitive functioning.

Conclusions. There was little support for an association between previous personality and awareness in dementia. However, increased carer burden was associated specifically with lack of awareness of cognitive-behavioural deficits not deficits in ADL, whereas lower awareness of ADL and not cognitive-behavioural deficits was associated with age. Awareness of memory appeared to be a metamemory capacity. Mood and age rather than personality and cognition are stronger predictors of awareness in early Alzheimer's disease.     

Exercise‐induced stress resistance is independent of exercise controllability and the medial prefrontal cortex

Exercise increases resistance against stress‐related disorders such as anxiety and depression. Similarly, the perception of control is a powerful predictor of neurochemical and behavioral responses to stress, but whether the experience of choosing to exercise, and exerting control over that exercise, is a critical factor in producing exercise‐induced stress resistance is unknown. The current studies investigated whether the protective effects of exercise against the anxiety‐ and depression‐like consequences of stress are dependent on exercise controllability and a brain region implicated in the protective effects of controllable experiences, the medial prefrontal cortex. Adult male Fischer 344 rats remained sedentary, were forced to run on treadmills or motorised running wheels, or had voluntary access to wheels for 6 weeks. Three weeks after exercise onset, rats received sham surgery or excitotoxic lesions of the medial prefrontal cortex. Rats were exposed to home cage or uncontrollable tail shock treatment three weeks later. Shock‐elicited fear conditioning and shuttle box escape testing occurred the next day. Both forced and voluntary wheel running, but not treadmill training, prevented the exaggerated fear conditioning and interference with escape learning produced by uncontrollable stress. Lesions of the medial prefrontal cortex failed to eliminate the protective effects of forced or voluntary wheel running. These data suggest that exercise controllability and the medial prefrontal cortex are not critical factors in conferring the protective effects of exercise against the affective consequences of stressor exposure, and imply that exercise perceived as forced may still benefit affect and mental health.     

Assessment of Pain as a Sequela in Patients Treated with Intracavitary Brachytherapy Accelerated Partial Breast Irradiation (IBAPBI): Preliminary Results of a Prospective Study

To assess pain rates and relationship to radiation‐induced fibrosis (RIF) in patients treated with intracavitary brachytherapy accelerated partial breast irradiation (IBAPBI). Thirty‐nine patients treated with IBAPBI were assessed prospectively for development of pain pretreatment, 1 month post‐IBAPBI, and every 6 months thereafter. A qualitative subjective Late Effects of Normal Tissue–Subjective Objective Management Analytical (LENT‐SOMA) questionnaire assessed pain. Use of pain medications was assessed as “no”, “sometimes”, or “regularly”. A quantitative objective validated pressure threshold (PTH) measured pain in the site of IBAPBI breast (index) and its mirror‐image in the nonirradiated breast (control). A validated tissue compliance meter (TCM) quantitatively assessed RIF in the index and control breasts at all time points. Mean ΔPTH(kg) and ΔTCM(mm) values reflected mean difference between the index and control breasts. Median follow‐up is 44 months (range 5–59 months). According to LENT‐SOMA, pain occurred in 89% at 1 and 24 months, 67% at 30 months, 30% at 36 months, 29% at 40 months, and 20% at 48 months. No patient used pain medication “regularly” but the use “sometimes” decreased over time: 61% at 1 month, 42% at 18 and 24 months, 13% at 36 months, and 10% at 40 months. Mean ΔPTH values, compared to Δ0 kg at baseline, peaked in absolute value by 1 month to ?1.36 kg (p < 0.0001), persisted after 18 months at ?0.99 kg (p < 0.0001) and 24 months at ?0.73 kg (p < 0.0001), and returned to nearly baseline by 40 months at ?0.11 kg (p < 0.57). Mean ΔPTH and ΔTCM correlated significantly with subjective patient reports of pain at each time point (p < 0.0001). To date, this is the first report to prospectively assess pain employing quantitative and qualitative inventories in patients treated with IBAPBI. Pain is experienced in the majority of patients experienced pain within the first 2 years, sometimes requiring a medication, and though subsides, it may persist 4 years after IBAPBI.     

Partnership for Sustainability in Cardiac Surgery to Address Critical Rheumatic Heart Disease in Sub-Saharan Africa: The Experience from Rwanda

Importance

Rheumatic heart disease (RHD) in the developing world results in critical disability among children, adolescents, and young adults—marginalizing a key population at its peak age of productivity. Few regions in sub-Saharan Africa have independently created an effective strategy to detect and treat streptococcal infection and mitigate its progression to RHD.

Objective

We describe a unique collaboration, where the Rwanda Ministry of Health, the Rwanda Heart Foundation, and an expatriate humanitarian cardiac surgery program have together leveraged an innovative partnership as a means to expand Rwanda’s current capacity to address screening and primary prevention, as well as provide life-saving cardiac surgery for patients with critical RHD.

Evidence review

Interviews with key personnel and review of administrative records were conducted to obtain qualitative and quantitative data on the recruitment of clinical personnel, procurement of equipment, and program finances. The number of surgical cases completed and the resultant clinical outcomes are reviewed.

Findings

From 2008 to 2013, six annual visits were completed. A total of 128 prosthetic valves have been implanted in 86 complex patients in New York Heart Association (NYHA) class III or IV heart failure, with excellent clinical outcomes (5 % 30-day mortality). Postoperative complications included a cerebrovascular accident (n = 1) and hemorrhage, requiring reoperation (n = 2). All procedures were performed with participation of local personnel.

Conclusions and relevance

This strategy provides a reliable and consistent model of sophisticated specialty care delivery; inclusive of patient-centered cardiac surgery, mentorship, didactics, skill transfer, and investment in a sustainable cardiac program to address critical RHD in sub-Saharan Africa.