Meningococcal infections: reducing the case fatality rate by giving penicillin before admission to hospital.

OBJECTIVE--To determine whether parenteral penicillin given before admission to hospital reduces the case fatality rate in patients with meningococcal disease. DESIGN--Retrospective analysis of 46 consecutive patients admitted to hospital with meningococcal disease from January 1986 to March 1991. SETTING--District general hospital. MAIN OUTCOME MEASURE--Hospital case fatality rate. RESULTS--None of the 13 patients given parenteral penicillin by the referring doctor before admission died, compared with eight deaths (24%) in 33 patients admitted without such treatment. CONCLUSION--Parenteral penicillin given before admission probably contributed to a reduction in the case fatality rate from meningococcal disease, and primary care physicians should be encouraged to give such treatment immediately on suspicion of the diagnosis before transferring the patient to hospital. Public health physicians are well placed to inform and alert general practitioners of the potential benefit of this action.     

Communication of results of necropsies in north east Thames region.

OBJECTIVE--To evaluate the adequacy of reporting of results of necropsy to referring clinicians and to general practitioners. DESIGN--Questionnaire survey of referring clinicians and general practitioners of deceased patients in four districts in North East Thames region. Patients were selected by retrospective systematic sampling of 50 or more necropsy reports in each district. SETTING--One teaching hospital, one inner London district general hospital, and two outer London district general hospitals. PARTICIPANTS--70 consultants and 146 general practitioners who were asked about 214 necropsy reports; coroners'' reports were excluded. MAIN OUTCOME MEASURES--Time taken for dispatch of final reports after necropsy, consultants'' recognition of the reports, general practitioners'' recognition of the reports or of their findings, and consultants'' recall of having discussed the findings with relatives. RESULTS--Only two hospitals dispatched final reports including histological findings (mean time to dispatch 144 days and 22 days respectively). 42 (60%) consultants and 83 (57%) general practitioners responded to the survey. The percentage of reports seen by consultants varied from 37% (n = 13) to 87% (n = 36); in all, only 47% (39/83) of general practitioners had been informed of the findings by any method. Consultants could recall having discussed findings with only 42% (47/112) of relatives. CONCLUSIONS--Communication of results of necropsies to hospital clinicians, general practitioners, and relatives is currently inadequate in these hospitals. IMPLICATIONS AND ACTION--A report of the macroscopic findings should be dispatched immediately after necropsy to clinicians and general practitioners; relatives should routinely be invited to discuss the necroscopic findings. One department has already altered its practice.     

序贯肠内外营养支持对AECOPD合并呼吸衰竭患者营养指标、胃肠黏膜功能和免疫功能的影响

摘要 目的：观察序贯肠内外营养支持在慢性阻塞性肺疾病急性加重期（AECOPD）合并呼吸衰竭患者中的应用价值。方法：选用随机数字表法将我院2019年1月-2020年12月期间收治的90例AECOPD合并呼吸衰竭患者分为肠内组（n=30）、肠外组（n=30）和序贯组（n=30）。对比三组患者营养指标、胃肠黏膜功能和免疫功能,观察并记录三组抗菌药物使用天数、住院天数和并发症发生率。结果：序贯组的抗菌药物使用天数、住院天数短于肠内组、肠外组（P<0.05）。序贯组营养支持2周后白蛋白（ALB）、前白蛋白（PA）、转铁蛋白（TF）均高于肠内组、肠外组（P<0.05）。序贯组营养支持2周后免疫球蛋白（Ig）A、IgM、IgG均高于肠内组、肠外组（P<0.05）。序贯组营养支持2周后D-乳酸、二胺氧化酶（DAO）均低于肠内组、肠外组（P<0.05）。三组并发症发生率组间对比无明显差异（P>0.05）。结论：序贯肠内外营养支持应用于AECOPD合并呼吸衰竭患者,可促进患者免疫功能提高,营养状况改善,同时还可促进胃肠黏膜功能恢复,缩短抗菌药物使用天数和住院天数。     

Capitation funding: population,age, and mortality adjustments for regional and district health authorities in England.

OBJECTIVE--To assess the effect of each of the components of the national capitation funding formula--population projections and age and mortality weighting--at regional and district level. DESIGN--Application of age-cost and mortality weights to the projected 1997 populations of regions and districts, based on the Department of Health public health common dataset. SETTING--Regional and district health authorities in England. RESULTS--The application of the age-cost and mortality weights to projected populations resulted in greater changes in the shares of weighted populations relative to the estimated 1991 population at district level (mean 0, range -17% to 28%) than at regional level (mean 0, range -9% to 6%). At district level mortality weights had less scope for influence (mean 0, range -9% to 14%) than population projections (mean 0, range -16% to 31%) or age weights (mean 0, range -20% to 30%). CONCLUSIONS--The adjustments to the 1991 population shares due to the application of the national capitation funding formula depend on the interaction of three elements: the projected population by age group, the age-cost weight, and the mortality weight. Since each is open to uncertainty, either in terms of measurement (projected population, particularly for births and the over 85s) or method (derivation of the age-cost and mortality weights), the formula should be implemented cautiously at district level. Ways should be considered of incorporating elements of uncertainty into the model. Further research is required on the elements and degree of uncertainty in each of these components, as well as on the relative health needs of different populations.     

Effectiveness of antibiotics in preventing meningococcal disease after a case: systematic review

Objective To summarise the evidence for the role of antibiotics in preventing further cases of meningococcal disease through chemoprophylaxis given to the index patient, household contacts, and children in day care settings after a single case.Design Systematic review.Methods Studies were identified by searching Embase (1983-2003), Medline (1965-2003), and CAB Health (1973-2003) and by contacting the World Health Organization and the European meningococcal disease surveillance network and examining references of identified papers. The review included all studies with at least 10 cases in which outcomes were compared between treated and untreated groups.Main outcome measure Subsequent cases of meningococcal disease 1-30 days after onset of disease in the index patient.Results Four observational studies and one small trial met the inclusion criteria. Meta-analysis of studies on chemoprophylaxis given to household contacts showed a significant reduction in risk (risk ratio 0.11, 95% confidence interval 0.02 to 0.58). The number needed to treat to prevent a case was estimated as 218 (121 to 1135). Primary outcome data were not available in studies of chemoprophylaxis given to the index patient: when prophylaxis had not been given, rate of carriage after discharge from hospital was estimated as 3% (0 to 6), probably an underestimate of the true rate. No studies of chemoprophylaxis in day care settings were identified that met the inclusion criteria.Conclusion There have been no high quality experimental trials looking at control policies for meningococcal disease. The best available evidence is from retrospective studies. The risk of meningococcal disease in household contacts of a patient can be reduced by an estimated 89% if they take antibiotics known to eradicate meningococcal carriage. Chemoprophylaxis should be recommended for the index patient and all household contacts.     

Comparison of immunisation rates in general practice and child health clinics.

OBJECTIVE--To compare immunisation uptake rates in general practice surgeries and community child health clinics. DESIGN--Cohort study using data from a computerised child health system. SETTING--Four health districts of North East Thames Regional Health Authority. SUBJECTS--3616 children born January to March 1990 and resident in the four districts at the end of January 1991. MAIN OUTCOME MEASURES--Immunisation uptake rates at 10-12 months of age, age at immunisation, scheduling performance at the two locations, and odds ratios of outstanding immunisations. RESULTS--80% of children registered at general practices had completed their third dose of pertussis immunisation compared with 68% of those at health clinics. Median ages at the third dose were 24 weeks and 29 weeks at the two locations respectively. Scheduling was more effective at general practice surgeries. Unscheduled immunisations were more likely to be given after the recommended age. Overall, children resident in rural and suburban areas had greater uptakes than those in inner cities. Odds ratios for not being fully immunised among children registered at health clinics were 1.4 times those among children immunised in general practice and 3.0 times greater among children resident in inner cities than among those in rural and suburban districts. Children who moved into a district, however, were no less likely to be fully immunised than children who were born there. CONCLUSIONS--The immunisation uptake rate was better in general practices than in child health clinics in both inner city and rural and suburban areas. Uptake may be increased with additional support to enable general practitioners to undertake immunisations, especially in inner cities.     

The evolving epidemiology of invasive meningococcal disease: a two-year prospective,population-based study in children in the area of Athens

In response to an increase in the incidence in invasive meningococcal disease (IMD) due to Neisseria meningitidis, a system of hospital- and laboratory-based surveillance was used in a prospective epidemiological and clinical assessment of IMD in children 0-13 years of age hospitalized in the Athens area between 1 January 1999 and 31 December 2000. The annual incidence of laboratory-confirmed disease was 10.2/100,000. Serogroup B strains were predominant. There was a sharp decrease in serogroup C from 19% of cases in 1999 to 3% in 2000 (P=0.013). Of note was the emergence of serogroup A responsible for 7% of the cases. The overall case fatality rate was 4.5%, but 2.8% for microbiologically confirmed cases. A remarkable decrease in disease severity assessed by admissions to intensive care units was noted during the second study year. Polymerase chain reaction-based methods for detection of meningococcal DNA were the sole positive laboratory test in 45% of the cases and the only test on which serogroup determination was based in 52% of groupable cases. The epidemiological and clinical profile of meningococcal disease appears to be rapidly evolving and close monitoring is required particularly for input into decisions regarding use of meningococcal vaccines.     

Predicting psychiatric admission rates.

OBJECTIVE--To determine the numbers of actual and expected psychiatric admissions for the residents of the district health authorities of England and to develop a model to indicate which social, health status, and service provision factors best explain the variation of the actual from the expected psychiatric admissions; to use this model to predict psychiatric admission for district health authorities as an aid to resource allocation. DESIGN--The actual psychiatric admission for district health authority residents were extracted from data of the 1986 Mental Health Enquiry. Expected admissions were calculated using the age, sex, and marital status structure of each district health authority and the national psychiatric admission rates related to age, sex, and marital status. Standardised psychiatric admission ratios were calculated as the ratios of the numbers of actual to expected psychiatric admissions. A wide range of social, health status, and service provision data were used as the explanatory variables in regression analyses to determine which combination of factors best explained the variation between districts of standardised psychiatric admission ratios. SETTING--The 168,652 psychiatric admissions recorded for the 1986 Mental Health Enquiry, after exclusion of mental handicap and psychogeriatric admissions. RESULTS--The actual number of psychiatric admissions varied from 79% above to 54% below the expected number of admissions from age, sex, and marital status for the districts of England. The most powerful variables to explain this variation were the rate of notification of drug misusers, standardised mortality ratios, and levels of illegitimacy in each district. A complex model was developed which could be used to predict district psychiatric admissions as an aid to resource allocation. A simpler model was also developed (which was less powerful than the more complex model) based on the underprivileged area score. One advantage of this model was that it could be used at the level of electoral wards as well as district health authorities.     

A Retrospective Study on the Epidemiology of Anthrax,Foot and Mouth Disease,Haemorrhagic Septicaemia,Peste des Petits Ruminants and Rabies in Bangladesh, 2010-2012

Anthrax, foot and mouth disease (FMD), haemorrhagic septicaemia (HS), peste des petits ruminants (PPR) and rabies are considered to be endemic in Bangladesh. This retrospective study was conducted to understand the geographic and seasonal distribution of these major infectious diseases in livestock based on data collected through passive surveillance from 1 January 2010 to 31 December 2012. Data analysis for this period revealed 5,937 cases of anthrax, 300,333 of FMD, 13,436 of HS, 247,783 of PPR and 14,085 cases of dog bite/rabies. While diseases were reported in almost every district of the country, the highest frequency of occurrence corresponded to the susceptible livestock population in the respective districts. There was no significant difference in the disease occurrences between districts bordering India/Myanmar and non-border districts (p>0.05). Significantly higher (p<0.01) numbers of anthrax (84.5%), FMD (88.3%), HS (84.9%) and dog bite/rabies (64.3%) cases were reported in cattle than any other species. PPR cases were reported mostly (94.8%) in goats with only isolated cases (5.2%) in sheep. The diseases occur throughout the year with peak numbers reported during June through September and lowest during December through April, with significant differences (p<0.01) between the months. The annual usages of vaccines for anthrax, FMD, HS and PPR were only 7.31%, 0.61%, 0.84% and 11.59% of the susceptible livestock population, respectively. Prophylactic vaccination against rabies was 21.16% of cases. There were significant differences (p<0.01) in the administration of anthrax, FMD and HS vaccines between border and non-border districts, but not PPR or rabies vaccines. We recommend that surveillance and reporting of these diseases need to be improved throughout the country. Furthermore, all suspected clinical cases should be confirmed by laboratory examination. The findings of this study can be used in the formulation of more effective disease management and control strategies, including appropriate vaccination policies in Bangladesh.     

Factors affecting uptake of measles,mumps, and rubella immunisation.

OBJECTIVE--To study factors affecting uptake of measles, mumps, and rubella immunisation. DESIGN--Cohort study using data from computerised child health systems. SETTING--10 health districts in North East Thames and North West Thames regions. SUBJECTS--7841 children born in January to March 1990 and resident in the districts up till the end of October 1991. MAIN OUTCOME MEASURES--Overall uptake of measles, mumps, and rubella immunisation, variation of uptake among groups of children, and odds ratio of being vaccinated against measles, mumps, and rubella. RESULTS--The overall uptake rate of measles, mumps, and rubella immunisation for the study cohort in the 10 districts was 82%. Wide variation was identified among children with different demographic characteristics. Lower uptake was associated with absent or incomplete primary immunisation, including omission of pertussis vaccine. Other factors affecting uptake included the type of resident district, birth order, where registered for immunisation (general practitioner or clinic), and one parent family status. CONCLUSIONS--Many districts have difficulties in meeting the 90% target for measles, mumps, and rubella immunisation, mainly because of the characteristics of their local population. To increase overall coverage, the health service should target families with adverse factors, especially those whose children have missed previous immunisations.     

How district health authorities organise cervical screening.

OBJECTIVES--To examine how district health authorities organised cervical screening with respect to Department of Health guidelines and to determine their assessment of the problems encountered. DESIGN--Postal questionnaire sent to all 190 district health authorities in England in 1989. PARTICIPANTS--190 District health authorities in England. MAIN OUTCOME MEASURES--Population coverage of screening, quality of smear testing, and follow up of abdominal test results in comparison with national guidelines for district cervical screening services, and problems encountered by districts. RESULTS--Replies were received from 178 (94%) of districts, in 143 of which the person named as responsible for cervical screening contributed. All districts implemented a computer managed scheme, 150 by the target date of 31 March 1988, but not all of these conformed with the guidelines. At the time of the survey only just over half called women in the target age group of 20-64 and only 70% expected to meet the target date of 13 March 1993 for completing the call. Considerable variation was evident among the schemes with regard to how they dealt with issues related to population coverage, quality of testing, and follow up of abnormal results. The problems most commonly identified by the districts (n = 174) were laboratory workload (107, 61%), computer software (104, 60%), availability of resources (78, 45%), non-attendance (77, 44%), rate of opportunistic screening (62, 36%), and investigation and treatment (60, 34%). CONCLUSIONS--Current practice in running cervical screening schemes needs to be examined to determine the extent to which it contributes to the goal of reducing mortality from cervical cancer.     

Association between Highly Active Antiretroviral Therapy and Type of Infectious Respiratory Disease and All-Cause In-Hospital Mortality in Patients with HIV/AIDS: A Case Series

Background

Respiratory manifestations of HIV disease differ globally due to differences in current availability of effective highly active antiretroviral therapy (HAART) programs and epidemiology of infectious diseases.

Objective

To describe the association between HAART and discharge diagnosis and all-cause in-hospital mortality among hospitalized patients with infectious respiratory disease and HIV/AIDS.

Material and Methods

We retrospectively reviewed the records of patients hospitalized at a specialty hospital for respiratory diseases in Mexico City between January 1st, 2010 and December 31st, 2011. We included patients whose discharge diagnosis included HIV or AIDS and at least one infectious respiratory diagnosis. The information source was the clinical chart. We analyzed the association between HAART for 180 days or more and type of respiratory disease using polytomous logistic regression and all-cause hospital mortality by multiple logistic regressions.

Results

We studied 308 patients, of whom 206 (66.9%) had been diagnosed with HIV infection before admission to the hospital. The CD4+ lymphocyte median count was 68 cells/mm³ [interquartile range (IQR): 30–150]. Seventy-five (24.4%) cases had received HAART for more than 180 days. Pneumocystis jirovecii pneumonia (PJP) (n = 142), tuberculosis (n = 63), and bacterial community-acquired pneumonia (n = 60) were the most frequent discharge diagnoses. Receiving HAART for more than 180 days was associated with a lower probability of PJP [Adjusted odd ratio (aOR): 0.245, 95% Confidence Interval (CI): 0.08–0.8, p = 0.02], adjusted for sociodemographic and clinical covariates. HAART was independently associated with reduced odds (aOR 0.214, 95% CI 0.06–0.75) of all-cause in-hospital mortality, adjusting for HIV diagnosis previous to hospitalization, age, access to social security, low socioeconomic level, CD4 cell count, viral load, and discharge diagnoses.

Conclusions

HAART for 180 days or more was associated with 79% decrease in all-cause in-hospital mortality and lower frequency of PJP as discharge diagnosis. The prevalence of poorly controlled HIV was high, regardless of whether HIV was diagnosed before or during admission. HIV diagnosis and treatment resources should be improved, and strengthening of HAART program needs to be promoted.     

Prevalence of de-O-acetylated serogroup C meningococci before the introduction of meningococcal serogroup C conjugate vaccines in the United Kingdom

Meningococcal serogroup C conjugate (MCC) vaccines have been introduced in the UK to combat the rise in serogroup C meningococcal disease. Serogroup C meningococci may occur naturally expressing either O-acetylated (Oac(+)) or de-O-acetylated (Oac(-)) polysaccharide capsules. In a small study in the USA in the 1970s 15% of serogroup C meningococcal case isolates were reported to be Oac(-) though the prevalence of these Oac(-) isolates has not been recorded in the UK. This is of interest as the first MCC vaccines to be introduced are Oac(+) and the potential impact of this on Oac(-) serogroup C isolates is unclear. Serogroup C isolates submitted to the Public Health Laboratory Service Meningococcal Reference Unit in January 1998 (n=113) and January 1999 (n=162) were investigated by dot blotting using monoclonals specific for Oac(+) and Oac(-) serogroup C polysaccharides. This revealed 12% Oac(-) isolates for both January 1998 and January 1999. The proportion of fatal cases was found to similar for both Oac(-) and Oac(+), 14 and 9% for 1998 and 5 and 3% for 1999, indicating that the pathogenic potential of these Oac(-) isolates is similar to Oac(+). The acetylation status of serogroup C isolates needs to be monitored throughout and after the introduction of MCC vaccines.     

Morbillivirus infection in live stranded, injured, trapped, and captive cetaceans in southeastern Queensland and northern New South Wales, Australia

We report serologic evidence of cetacean morbillivirus (CMV) infection in five of eight cetacean species found live stranded, injured, or trapped along the coast of southeastern Queensland and northern New South Wales, Australia between December 2005 and January 2011. Antibody to CMV was detected in 13 of 27 (48%) wild cetaceans sampled. Antibody prevalence was significantly higher in clinically diseased (69%) compared to nondiseased (18%) animals (P=0.018). There was high antibody prevalence (83%, n=6) in melon-headed whales (Peponocephala electra). Two of 13 (15%) captive cetaceans sampled between November 2005 and January 2011 had CMV antibodies and, as infection was unlikely to have occurred while in captivity, CMV infection appears to have been present in Australian wild cetaceans since at least 1985. These results indicate that morbillivirus infection is occurring without widespread cetacean mortality in this region. However, as the deaths of two immature Australian offshore bottlenose dolphins (Tursiops truncatus) were attributed to CMV infection, morbillivirus infection should be included in the differential diagnosis of disease in cetaceans in Australia. Captive cetacean populations may be prone to significant mortality as a result of CMV introduction, so strict quarantine procedures should be enforced when injured or stranded cetaceans are hospitalized and rehabilitated at Australian zoos and marine parks.     

Assessment of a two-step nucleic acid amplification assay for detection of Neisseria meningitidis followed by capsular genogrouping

Immediate prevention of meningococcal disease relies in part on the prompt treatment with antibiotics of household and other close contacts of cases; however intervention with effective vaccination relies on identification of serogroup-causing strains. Parenteral antibiotic for patient with suspected meningococcal disease before hospital admission is currently recommended. Laboratory standard methods are hindered by failure to detect bacteria by this medical approach to improve patient prognosis. We assessed two polymerase chain reaction (PCR) assays to detect (crgA) and define the serogroups (siaD, orf-2, and ctrA) of Neisseria meningitidis in 120 cerebrospinal fluid (CSF) samples from positive cases (culture or antigen detection or direct smear). The PCR sensitivity for the identification of N. meningitidis was 100% (95% confidence interval, CI, 96-100%) compared to a sensitivity of 46% for culture (95% CI 37-55%), 61% for latex agglutination test (95% CI 52-70%), and 68% for Gram stain (95% CI 59-76%); PCR specificity was 97% (95% CI 82-100%). PCR correctly identified the serogroups A, B, C, W135, Y, and X in CSF samples with a sensitivity of 88% (95% CI 80-93%); the primer sets were 100% specific. The introduction of PCR-based assays shall increase laboratory confirmed cases, consequently enhancing surveillance of meningococcal disease.     

Seasonal variation in onset of myocardial infarction--a 7-year single-center study in Italy

Like many other serious acute cardiovascular and cerebrovascular events, acute myocardial infarction (AMI) shows seasonal variation, being most frequent in the winter. We sought to investigate whether age, gender, and hypertension influence this pattern. We studied 4014 (2259 male and 1755 female) consecutive patients with AMI presenting to St. Anna Hospital of Ferrara, Italy between January 1998 and December 2004. Some 1131 (28.2%) of the AMI occurred in persons <65 yrs of age, and 2883 (71.8%) in those > or =65 yrs of age. AMI was over-represented in males (82% in the <65 yr group vs. 56.6% in the > or =65 yr group (chi2=13.99; p<0.001). Hypertension had been previously documented in 964 (24%) of the cases. There were 691 (17.2%) fatal case outcomes; fatal outcomes were significantly higher among the 3054 normotensive (n=614 or 20.1%) than the 964 hypertensive cases (n=77 or 8%; chi2=74.94, p<0.001). AMIs were most frequent in the winter (n=1076 or 26.8% of all the events) and least in the summer (n=924 or 23.0% of all the events; chi2=12.36, p=0.007). The greatest number of AMIs occurred in December (n=379 or 9.44%), and the lowest number in September (n=293 or 7.3%; chi2=11.1, p=0.001). Inferential chronobiological (Cosinor) analysis identified a significant annual pattern in AMI in those > or =65 yrs of age, with a peak between December and February-January for the total sample (p<0.005), January for the sample of males (p=0.014), February for fatal infarctions (p=0.017), and December for non-fatal infarctions (p=0.006). No such temporal variations were detected in any of these categories in those <65 yrs of age. The annual pattern in AMI was also verified by Cosinor analysis in the following hypertensive subgroups: hypertensive males (n=552: January, p=0.014), non-fatal infarctions in hypertensive patients (n=887: January, p=0.018), and elderly normotensives (n=1556: November, p=0.007).     

Clinical Outcomes in Low Risk Coronary Artery Disease Patients Treated with Different Limus-Based Drug-Eluting Stents - A Nationwide Retrospective Cohort Study Using Insurance Claims Database

The clinical outcomes of different limus-based drug-eluting stents (DES) in a real-world setting have not been well defined. The aim of this study was to investigate the clinical outcomes of three different limus-based DES, namely sirolimus-eluting stent (SES), Endeavor zotarolimus-eluting stent (E-ZES) and everolimus-eluting stent (EES), using a national insurance claims database. We identified all patients who received implantation of single SES, E-ZES or EES between January 1, 2007 and December 31, 2009 from the National Health Insurance claims database, Taiwan. Follow-up was through December 31, 2011 for all selected clinical outcomes. The primary end-point was all-cause mortality. Secondary end-points included acute coronary events, heart failure needing hospitalization, and cerebrovascular disease. Cox regression model adjusting for baseline characteristics was used to compare the relative risks of different outcomes among the three different limus-based DES. Totally, 6584 patients were evaluated (n=2142 for SES, n=3445 for E-ZES, and n=997 for EES). After adjusting for baseline characteristics, we found no statistically significant difference in the risk of all-cause mortality in three DES groups (adjusted hazard ratio [HR]: 1.14, 95% confidence interval [CI]: 0.94-1.38, p=0.20 in E-ZES group compared with SES group; adjusted HR: 0.77, 95% CI: 0.54-1.10, p=0.15 in EES group compared with SES group). Similarly, we found no difference in the three stent groups in risks of acute coronary events, heart failure needing hospitalization, and cerebrovascular disease. In conclusion, we observed no difference in all-cause mortality, acute coronary events, heart failure needing hospitalization, and cerebrovascular disease in patients treated with SES, E-ZES, and EES in a real-world population-based setting in Taiwan.     

Prevalence of clinical malaria and household characteristics of patients in tribal districts of Pakistan

BackgroundMalaria, disproportionately affects poor people more than any other disease of public health concern in developing countries. In resource-constrained environments, monitoring the occurrence of malaria is essential for the success of national malaria control programs. Militancy and military conflicts have been a major challenge in monitoring the incidence and controlling malaria and other emerging infectious diseases. The conflicts and instability in Afghanistan have resulted in the migration of refugees into the war-torn tribal districts of Pakistan’s Khyber Pakhtunkhwa (KPK) province and the possible introduction of many contagious epidemics. Although malaria is very common in all tribal districts, molecular, clinical and epidemiological data are scarce in these high-burden districts. Therefore, for the proper surveillance, detection, and control of malaria, obtaining and analyzing reliable data in these districts is essential.Methodology/Principal findingsAll 1,127 malaria-suspected patients were sampled within the transmission season in the tribal districts of KPK province between March 2016 to December 2018. After a detailed demographic and clinical investigation of malaria-suspected patients, the data were recorded. The data of the control group was collected simultaneously at the same site. They were considered as uncomplicated cases for statistical analyses. Blood samples were collected from malaria-suspected patients for the detection of Plasmodium species using microscopy and nested PCR (nPCR). Microscopy and nPCR examination detected 78% (n = 882) and 38% (n = 429) Plasmodium-positive patients, respectively. Among1,127 of 429nPCR detected cases with both species of malaria, the frequency of complications was as follows: anemia (n = 71; 16.5%), decompensated shock (n = 40; 9%), hyperpyrexia (n = 117; 27%), hyperparasitaemia (n = 49; 11%) hypoglycemia (n = 45; 10.5%), jaundice (n = 54; 13%), multiple convulsions (n = 37; 9%), and petechia (n = 16; 4%). We observed that 37% (n = 157 out of 429) of those patients infected by both Plasmodium species were children between the ages of 1 and 15 years old. The results revealed that Bajaur (24%), Kurram (20%), and Khyber (18%) districtshada higher proportion of P. vivax than P. falciparum cases. Most of the malaria cases were males (74%). Patients infected by both Plasmodium species tended to less commonly have received formal education and ownership of wealth indicators (e.g., fridge, TV set) was lower.Conclusions/SignificanceMalaria in tribal districts of the KPK province largely affects young males. P. vivax is a major contributor to the spread of malaria in the area, including severe malaria. We observed a high prevalence of P. vivax in the Bajaur district. Children were the susceptible population to malaria infections whereas they were the least expected to use satisfactory prevention strategies. A higher level of education, a possession of TV sets, the use of bed nets, the use of repellent fluids, and fridges were all associated with protection from malaria. An increased investment in socio-economic development, a strong health infrastructure, and malaria education are key interventions to reduce malaria in the tribal districts.     

The Middle Care Round

As an experiment in postgraduate education a 25-week course in weekly ward rounds for general practitioners and local authority nurses was established at a district general hospital of 340 beds. A total of 73 rounds were held, divided into 12-, 4-, and 9-week courses, from January to December 1969. Ninety-nine general practitioners and district nurses (including health visitors) attended one or more of these rounds. Seventeen consultants participated and there were 273 doctor attendances and 190 nurse attendances. The average attendance per round was four doctors and two nurses. The number of rounds conducted by each of the consultants throughout the course varied from two to six. This paper presents an evaluation of the course.