Traditional birth attendants in an endemic area of tetanus neonatorum in Thailand: Pitfalls in the control program

A survey of the characteristics of traditional birth attendants in Krabi Province, Thailand, where the incidence rate of tetanus neonatorum was the highest in the country, was conducted in order to obtain background information necessary for planning a training curriculum and to evaluate previous training courses. Five second year medical students were used as research assistants.After the questionnaire was constructed and tested, the students went to visit a sample of 116 traditional birth attendants (TBAs) to interview them about their personal backgrounds, techniques and practices in delivery and beliefs and attitudes towards midwifery.The study revealed that these TBAs were a mixture of Buddhist and Islamic females whose literacy rate was 53 percent. Ninety-one per cent knew about the availability of an injection for antenatal care at the health center, but only about half knew that it was for tetanus prevention. More than half provided antenatal care at their own home but 85 per cent conducted delivery at the client's home. About eighty per cent of the TBAs claimed that sterilization of instruments was performed. However, dressing of the umbilical cord was done inappropriately using various kinds of powders by about 40 per cent. The majority of TBAs had experience with complicated labors but only 30 per cent were referred, perhaps, due to excessive self-confidence and supernatural beliefs.The trained TBAs possessed a higher level of knowledge of immunization and sterile techniques for cord cutting and dressing of the stumps of the umbilical cord than the untrained group. However, knowledge of sterilization of instruments was not significantly different, indicating a need to improve teaching in this area.It was concluded that past training programs had increased the knowledge of the TBAs. However, they were not effective enough to eradicate tetanus neonatorum and to prevent other forms of perinatal morbidity and mortality. Refresher courses emphasizing the dangers of improper dressing of the stump, increasing postnatal visits by professional midwives to detect and avert risks to the newborns and mass immunizations of females of reproductive age are clearly required.Virasakdi Chongsuvivatwong is Chief of Epidemiology Unit, Faculty of Medicine, Prince of Songkla University; Luan Bucharkorn is the Head of Provincial Public Health Office in Krabi; Ruthaiporn Treetrong is Assistant Professor in Faculty of Nursing, Prince of Songkla University.This research was supported by the Ford Foundation, Grant number 880-0312A.     

Review of 336 patients with hepatocellular carcinoma at Songklanagarind Hospital

AIM:To determine the clinical presentations, survival and prognostic factors of hepatocellular carcinoma (HCC) in Southern Thailand.METHODS:Retrospective analysis was performed on the 336 hepatocellular carcinoma patients treated at Songklanagarind hospital between 1 January 1991 and 31 January 1999.RESULTS:Of these 336 patients, 276 were males and 60 were females. The mean age was 54.4 years. The common symptoms and signs were abdominal pain and hepatomegaly. The most common presentation of tumor was a dominant mass with daughter nodules. Portal vein involvement was found in 50% of total. Extrahepatic metastasis was found in 13%, and the lung was the most common site. There were 65.4% with evidence of cirrhosis and half of them were in Child's class B. HBsAg was positive in 72.6%. Regarding a(c)Okuda's tumor staging, 15%, 61% and 24% were stage I, II and III, respectively. Overall median survival was 2.1 months (11.5 2.6 and 0.7 months for stage I, II and III respectively). Treatments of HCC improved patient survival (5.5 months vs 1.6 months for untreated patients). Most common causes of death were hepatic failure. Using multivariate analysis, the prognostic factors identified were tumor staging, alpha-fetoprotein level above 10000&mgr;gcenter dotL(-1), extrahepatic metastasis, portal vein thrombosis and treatment.CONCLUSION:HCC in Thailand is a fatal disease with poor outcome due to late presentation and high prevalence of liver cirrhosis. Early detection and proper management may improve outcome.     

Decline in pulmonary function during chronic hepatitis C virus therapy with modified interferon alfa and ribavirin

Rare interstitial lung disease cases have been reported with albinterferon alfa‐2b (albIFN) and pegylated interferon alfa‐2a (Peg‐IFNα‐2a) in chronic hepatitis C virus (HCV) patients. Systematic pulmonary function evaluation was conducted in a study of albIFN q4wk vs Peg‐IFNα‐2a qwk in patients with chronic HCV genotypes 2/3. Three hundred and ninety‐one patients were randomly assigned 4:4:4:3 to one of four, open‐label, 24‐week treatment groups including oral ribavirin 800 mg/d: albIFN 900/1200/1500 μg q4wk or Peg‐IFNα‐2a 180 μg qwk. Standardized spirometry and diffusing capacity of the lung for carbon monoxide (DLCO) were recorded at baseline, weeks 12 and 24, and 6 months posttreatment, and chest X‐rays (CXRs) at baseline and week 24. Baseline spirometry and DLCO were abnormal in 35 (13%) and 98 (26%) patients, respectively. Baseline interstitial CXR findings were rare (4 [1%]). During the study, clinically relevant DLCO declines (≥15%) were observed in 173 patients (48%), and were more frequent with Peg‐IFNα‐2a and albIFN 1500 μg; 24 weeks posttreatment, 57 patients (18%) still had significantly decreased DLCO, with a pattern for greater rates with albIFN vs Peg‐IFNα‐2a. One patient developed new interstitial CXR abnormalities, but there were no clinically relevant interstitial lung disease cases. The risk of persistent posttreatment DLCO decrease was not related to smoking, alcohol, HCV genotype, sustained virologic response, or baseline viral load or spirometry. Clinically relevant DLCO declines occurred frequently in chronic HCV patients receiving IFNα/ribavirin therapy and commonly persisted for ≥6 months posttherapy. The underlying mechanism and clinical implications for long‐term pulmonary function impairment warrant further research.     

Development of nanodispersion-based sildenafil metered-dose inhalers stabilized by poloxamer 188: a potential candidate for the treatment of pulmonary arterial hypertension

Objectives: This study aims to formulate nanodispersion-based sildenafil metered-dose inhalers (MDIs) by using poloxamer 188 (P188) as a stabilizer; to evaluate their stability, aerosol characteristics, cytotoxicity, and inflammatory effects; and to investigate the effects of P188 on stability and aerosol characteristics of the MDIs.

Methods: The stability and uniformity of the formulations were evaluated by high-performance liquid chromatography method. The aerosol characteristics were evaluated by the Next Generation Impactor. The cytotoxicity and inflammatory effects on respiratory epithelial cells and alveolar macrophages were evaluated by MTT assay and TNF-α, IL-1β, and NO assay, respectively.

Results: The optimal formulation was stable and well-uniform after 6?months. The fine particle fraction and mass median aerodynamic diameter (MMAD) of the formulation were 61.9%?±?2.5% and 1.69?±?0.06?µm, respectively. The formulation was found to be nontoxic to respiratory epithelial cells and did not induce the inflammatory responses of alveolar macrophages. A positive correlation between P188 concentration and MMAD of the MDIs was observed. P188 possesses an ability to prevent the growth of sildenafil citrate monohydrate crystals in the formulations.

Conclusions: The findings provided a basis for the development of sildenafil MDI as a potential candidate for the treatment of pulmonary arterial hypertension.     

Comparison of Accessibility among Vision-impaired Patients Visiting Mobile and Stationary Hospitals in Rural Bangladesh

The aim of this study is to compare accessibility of vision-impaired (VI) patients to other eyecare centres before attending the mobile and stationary hospitals. Under a cross-sectional study design, VI patients were consecutively enrolled if they visited one of the three Impact Foundation Hospitals—one mobile and two stationary hospitals. The cost and service output of all hospitals were also reviewed; 27.7% of patients at the mobile and 36.8% at the two stationary hospitals had sought eyecare at other health facilities in the past. Mobile hospital patients lived closer to the hospital but spent more time in travelling, bore less direct cost, needed less extra support, and had a higher level of satisfaction on the service. They also identified more barriers to access eyecare in the past. The mobile hospital had a higher percentage of patients with accessibility problems and should continue to help the remote population in overcoming these problems.Key words: Health science accessibility, Mobile hospital, Vision impairment, Bangladesh     

Thermal behavior of water in the selected starch- and cellulose-based polymeric hydrogels

In a polymer-water matrix, freezable water is depressed due to either porosity confinement or interaction. The aim of the study was to examine water crystallization/melting depression by sub-ambient differential scanning calorimetry. The selected starch- and cellulose-based polymers including pre-gelatinized starch (PS), sodium alginate, sodium starch glycolate, hydroxypropylmethyl cellulose (HPMC), sodium carboxymethyl cellulose, and croscarmellose sodium were employed. The pre-treated with ambient humidity (85-100% relative humidity, at 30.0+/-0.2 degrees C for 10 days) and with excess water (hydrogels) samples were subjected to between 25 and -150 degrees C cooling-heating cycle at 5.00 degrees C/min rate. The volume fractions of hydrogels were measured by light scattering technique. It was observed that all polymers but PS and HPMC with ambient humidity presented freezable water in two distinct fractions namely bound water where crystallizing/melting temperature was depressed and bulk water. The water transition in samples with various contents exhibited the pattern as a polymer solution, thus rather than confinement, the depression was due to interaction. The volume fraction-melting temperature data derived from endotherms of hydrogels were successfully fitted to Flory's model (r(2): 0.934-0.999). The Flory's interaction parameters (chi(1)) were found to vary between 0.520 and 0.847. In addition, the smaller the value of chi(1), the larger melting was depressed, i.e., stronger affinity for water.     

Prediction score for effective bleeding control using recombinant activated factor VII in perioperative nonhemophilic patients

Background

Although there has been growing evidence from off-label use of recombinant activated factor VII (rFVIIa) in surgical bleeding, there is limited information on prediction scores.

Methods

A retrospective study was conducted from 2004 to 2009. The primary outcome was efficacy of bleeding control. Multivariate logistic regression was performed to develop a new prediction score for success of rFVIIa.

Results

A total of 320 bleeding episodes from 243 nonhemophilic patients who underwent surgery were analyzed. Effective bleeding control was demonstrated in 153 patients. The overall in-hospital mortality rate was 40%. Multivariate analysis identified 4 independent predictors for effective bleeding control: timing of rFVIIa administration, intraoperative blood loss, postoperative international normalization ratio values, and total units of platelets transfused. A rFVIIa success prediction score was developed.

Conclusions

The use of this new prediction score may support decision making by identifying patients with a high probability of obtaining effective bleeding control from rFVIIa therapy.     

Thunderclap headache as a presentation of spontaneous spinal epidural hematoma with spontaneous recovery

Abstract

Background

Spontaneous spinal epidural hematoma (SSEH) is a rare spinal cord compression disorder. Thunderclap headache mimicking subarachnoid hemorrhage as an initial manifestation of this disorder has been scarcely reported. Moreover, the neurological outcome of conservative treatment is satisfactory only in some clinical settings. The unusual presentation and mechanisms for spontaneous recovery of SSEH are discussed.

Objective

To report a case of SSEH that presented with acute severe headache that mimicked subarachnoid hemorrhage. After a period of neurological deficit, spontaneous improvement was seen, which progressed to full recovery without neurosurgical intervention.

Findings

A 62-year-old man presented with acute occipital headache and neck stiffness for which subarachnoid hemorrhage was initially suspected. An emergency computed tomographic brain scan and cerebrospinal fluid analysis excluded subarachnoid hemorrhage. Later, he developed acute paraparesis, hypoesthesia up to the fourth thoracic dermatomal level (T4) as well as bowel and bladder dysfunction. The magnetic resonance imaging eventually revealed spinal epidural hematoma, located anterior to C7 through T4 spinal level. He had no previous history of spinal injury, systemic, and hematological disorders. The neurological recovery began 20 hours after the onset and continued until complete recovery, 4 months after the onset without neurosurgical intervention.

Conclusion

SSEH could sometimes imitate subarachnoid hemorrhages when it located in the cervical region. Spontaneous recovery of SSEH without surgical intervention might be possible in cases with continuing neurological recovery, although the recovery began much later in the clinical course.     

The association between CYP 2C9 polymorphism and bone health

PurposeThere is a strong scientific rationale to support the view that cytochrome P450 (CYP P450) enzyme-inducing AEDs induce bone loss in patients with epilepsy. However, no study has investigated the association between CYP 2C9 polymorphism and bone mineral density (BMD), 25-hydroxyvitamin D or parathyroid hormone levels in patients with epilepsy. This study sought to determine the association between BMD and CYP 2C9 polymorphism.MethodsNinety-three patients taking phenytoin as monotherapy were examined for CYP 2C9 polymorphism, vitamin D level and parathyroid hormone level and underwent basic chemistry testing. The bone mineral density of the lumbar spine and left femur were measured using dual-energy X-ray absorptiometry.ResultsThe results indicated that about 18.3% of the patients with epilepsy were positive for CYP2C9*3. Furthermore, bone mineral density was associated with CYP 2C9 polymorphism epileptic patients. Specifically, patients with 2C9 polymorphism had higher T-scores and Z-scores of the femoral neck (p = 0.02 and 0.04, respectively), but not of the lumbar spine (p = 0.27 and 0.06, respectively). There was also a trend of having higher serum PTH levels and statistically significantly lower 25-hydroxyvitamin D levels in patients with wild type than in those compared with CYP 2C9 polymorphism (p = 0.05 and 0.03, respectively). Additionally, the patients with CYP 2C9 polymorphism had higher plasma levels of phenytoin, particularly when compared with those with wild type (p = 0.01). However, there was no association between serum levels of phenytoin and low BMD at femoral neck or lumbar spine.ConclusionCYP 2C9 polymorphism is associated with higher BMD, independent of plasma levels of phenytoin.