Knowledge, attitude, and practice regarding atrial fibrillation among primary care physicians: the potential role of postgraduate training

@#Introduction: Atrial fibrillation (AF) is known to lead to stroke and thromboembolism, causing a five-fold increase in the risk of stroke and almost doubling the mortality rate. Optimal anticoagulant therapy is effective in reducing AF-related death. However, prescription of anticoagulants in AF in East Asian countries has been low, ranging from 0.5% to 28%. This study aimed to determine whether vocational training in family medicine improves primary care physicians’ knowledge, attitude, and practice in the management of AF. Method: This investigation was a cross-sectional study carried out during centralized workshops for two groups of trainees using a validated questionnaire: (i) junior trainees were newly enrolled postgraduate trainees in the Graduate Certificate in Family Medicine (GCFM) program, and (ii) senior trainees were postgraduate trainees in Advance Training in Family Medicine (ATFM) programs of the Academy of Family Physicians of Malaysia (AFPM). Results: A total of 223 trainees (127 junior and 96 senior) participated in this study. Only 55.2% of the trainees passed the knowledge test; senior trainees were more likely to pass the knowledge test compared to junior trainees (69.8% vs. 44.1%, p <0.001). Female trainees were significantly more likely to pass the knowledge test than male trainees. While the attitude of senior and junior trainees was similar, more of the latter group worked in public clinic that provide better support where there is better support for outpatient anticoagulation treatment (e.g., same-day INR test, direct access echocardiogram, and warfarin in in-house pharmacy). Conclusion: Vocational training in family medicine appears to improve primary care physicians’ knowledge regarding the management of AF. Better knowledge will help vocationally trained primary care physicians to provide anticoagulation treatment for AF within primary care clinics. More optimal AF management within primary care can take place if the identified barriers are addressed and a shared care plan can be implemented.

Evaluation of melaleuca cajuputi [family: myrtaceae] essential oil in aerosol spray cans against dengue vectors in low cost housing flats

Melaleuca cajuputi essential oil in aerosol spray was evaluated against the dengue vectors Aedes aegypti andAe. Albopictus at low cost housing flats in Section 10, Setapak, Kuala Lumpur, Malaysia. Essential oil in aerosol viz: 5% and 10% of concentrations were sprayed for 5 seconds each towards hung mosquitoes in 5 cylindrical net cages. Aerosol weights were recorded before and after spraying to determine discharge rates. Knockdown and mortality number were observed and compared to MS standard aerosol which contain 0.07% prallethrin and 0.05% d-phenothrin as positive control and aerosol contain 40% kerosene and 60% LPG was used as negative control. High knockdown and mortality was observed in both species of mosquitoes towards MS standard aerosol. There was a significant difference [P < 0.05] of mortality and knockdown between 5% and 10% of essential oil aerosol and 5% and 10% essential oil between MS standard. For 5% essential oil, mean percentage [%] of knockdown and mortality of Ae. Aegypti displayed slightly higher compared to Ae. albopictus. Spraying with 5% M. cajuputi essential oil aerosol indicated a knockdown of Ae. Aegypti 5.60 +/- 1.18 and mortality of 22.90 +/- 4.22 while Ae. albopictus showed 4.60 +/- 0.89 knockdown and 20.00 +/- 2.85 mortality. The 10% essential oil concentration gave 23.60 +/- 1.68 knockdown and 48.05 +/- 0.37 mortality for Ae. aegypti. Ae. Albopictus gave 23.00 +/- 3.16 knockdown and 44.20 +/- 2.10 mortality respectively. Extracts of essential oils does possessed an adulticidal effects and could be considered and utilized for future dengue vectors control

Evaluación de tees metodologías de recuperaciónde embriones en caninos utilizaando un modelo postmoreem / Evaluatin of thrree techniques to recover canine embryos using a post-mortem model

Objetivo. Evaluar tres técnicas de recuperación de embriones, utilizando como modelos de simulación oocitos desnudos introducidos en úteros recuperados post-mortem. Materiales y métodos. Se introdujeron 10 oocitos en el extremo ovárico de cada cuerno. El tratamiento 1 (T1) consistió en realizar una punción a nivel del extremo ovárico de cada cuerno para introducir el medio de lavado. Se incidió la base de cada cuerno para ubicar un catéter TOMCAT 8-Fr, recuperando el medio en una caja de petri. En el tratamiento 2 (T2) se realizó una punción en el extremo ovárico de cada cuerno pero la recuperación de los oocitos se realizó con un catéter de 56 cm de longitud que se pasó transcervicalmente hasta la base de cada cuerno. En el tratamiento 3 (T3) se utilizó el mismo tipo de catéter por vía transcervical y el lavado y la recuperación se realizó a través del mismo catéter. Resultados. El número de estructuras recuperadas fue de 7.3 ± 2.4 (73%) para el T1; 8.5 ± 1.9 (85%) para el T2 y de 5.8±2.2 (58%) para el T3. La tasa de recuperación fue similar para T1 y T2, pero significativamente mayores que para el T3 (p>0.01). Conclusiones. Las técnicas que se proponen son menos invasivas y tienen resultados comparables a otros estudios donde realizan histerectomía y laparotomía. Con este tipo de técnicas, se disminuye el trauma generado por incisiones quirúrgicas y la posible generación de adherencias. Adicionalmente permitirían realizar recuperaciones de embriones no quirúrgicas en caninos.

Objective. To compare three embryo recovery techniques, using simulation models in which denuded oocytes were introduced in recently recovered uteri. Materials and methods. Ten denuded oocytes were deposited in the ovarian tip of each uterine horn using a Tomcat catheter. Technique one (T1) consisted of a puncture made close to the ovarian tip of the uterine horn with a 20 G needle connected to a 20 ml syringe loaded with 20 ml of PBS (flush medium). In the base of each horn, a 1 cm incision was made to place the Tomcat catheter from which the fluid was recovered into a Petri dish. For technique two (T2) a puncture in the ovarian tip was made as in T1 but the oocytes were recovered with a catheter that was passed through the cervix and the fluid recovered in a Petri dish. In technique three (T3) a catheter was inserted through the cervix and was used for pumping the collection media in and out. Results. The number of structures recovered per horn was 7.3 ± 2.4 (73%) for T1; 8.5 ± 1.9 (85%) for T2 and 5.8±2.2 (58%) for T3. The first two techniques were not significantly different (p>0.01) and showed better recovery rates than the technique used in T3. Conclusions. Canine embryos could be retrieved using a less invasive technique by passing an 8-french catheter through the cervix thereby reducing the damage to the uterus and the possible generation of adhesions.

Study of various epidemiological and metabolic criteria in diabetic children and adolescence attending pediatric outpatient clinic of NIDE

Type 1 diabetes mellitus is one of the greatest challenges in public health and one of the most frequent chronic diseases in the pediatric age. The aim of this study was to study the epidemiological and metabolic criteria of 398 diabetic children who attended the outpatient pediatric clinic with determination of beta cell function of theses patients. Study of the age of onset of diabetes, sex distribution, residency, with other epidemiological factors among diabetic patients, attended the outpatient clinic of NIDE during year 2008, who accepted to participate in this study. All patients were subjected to full history taking, thorough clinical examination and full laboratory investigations including: CBC, liver enzymes, s. creatinine, lipid profile, including total cholesterol LDL-cholesterol, HDL-cholesterol and triglycerides, fasting c-peptide, Glycated HbA1c, and estimation of microalbuminuria. There was positive correlations between: Age [mean = 10.34 +/- 12.7 y.] and BMI [mean = 27.79 +/- 8.66 kg/m2], systolic B.P. [105.23 + 6.86 mmHg.] and total cholesterol [mean = 175.74 +/- 38.09 mg/dl] and systolic B.P. and triglycerides [mean = 83.88 +/- 47.46 mg/dl], and a highly positive correlations as regarding age [mean = 10.34 +/- 12.7 y.] and glycated HbA1c [mean = 9.79 +/- 2.38%]. There were no significant difference between diabetic group with c-peptide < 1 ng/ml and group with preserved beta cell function with c-peptide> 1 ng/ml as regards: Glycated HbA1c, s. cholesterol, s. cholesterol LDL, microalbuminuria, BMI and age. While there was a positive statistical difference between both groups as regards s. triglycerides [mean=75.27+31.17mg/ dl and 102.27+49.6 mg/dl]. There was no significant difference as regarding sex distribution as the female percentage was 51% while male represented 49%. The family history of diabetes was positive in 6.7% as regards father, 5.2% as regards mother, 4% as regards siblings. The study of beta cell function was done through estimation of fasting c-peptide levels. 93.7% were with fasting c-peptide level < 1 ng/ml, while 6.3% were preserved beta cell function as fasting c-peptide levels were > 1 ng/ml. Only 34.8% of the patients were doing continues home blood glucose monitoring with glucose sensors, 25.8% were doing the monitoring only with visual strips, while 39.4% of the diabetic children did not doing any home blood glucose monitoring. The glycated HbA1c was <7% in 31%, 7-8% in 22%, > 8-9% in 14% and >9% in 33%. The study of BMI of the patients showed that 56% were not overweight, [BMI <25], 27% started to be overweight, [BMI 25-30], 14% were obese, [BMI 30-<40] while 3% only were with severe obesity [BMI >40]. According to the definition of metabolic syndrome criteria, the study of the metabolic criteria of the study group showed that 112, [28.1%] patients were with positive one metabolic criteria, 56 patients, [14%] with 2 positive metabolic criteria and 36 patients, [9%] with 3 positive metabolic criteria. So, in addition to the presence of hyperglycemia, 23% of the young diabetic patients fulfilled the criteria of metabolic syndrome

Retrospective epidemiological study, with focus on acute and chronic managements, of patients attended the pediatric outpatient clinic of National Institute of Diabetes and Endocrinology, Cairo, Egypt

Diabetes mellitus is the most common endocrine metabolic disorder of childhood. It is widely spread all over Egypt as its prevalence was found to be 1.09 per 1000 among school aged children. The aim of this work was to do a retrospective epidemiological study of the records of diabetic children attended the outpatient pediatric clinic in NIDE. The files of 851 diabetic children were examined retrospectively without any reference to the personal data. Out of them, the files of 200 diabetic patients were also studied for determination of chronic management results represented by the type of insulin regimen used and estimation of the daily insulin dose per kg. We also assessed the outcome management of acute ketoacidosis from the files of 200 patients admitted to the ICU and npatient departments. All the resulted data had been subjected to SPSS statistical program. The results showed that there is no statistical differences between male, [n = 424] to female, [n = 427] distribution. The results of this retrospective study showed that the mean age of onset of diabetes in children attended the outpatient pediatric clinic of National Institute of Diabetes was [mean = 8.37 10.96 y]. The present study showed also that there was a decrease of age of onset of diabetes among diabetic children as the age of onset between 5- <10 years were the highest percentage [46%]. As regards the insulin regimen used by the diabetic children, 17.5% used conventional insulin therapy, 11% used modified insulin therapy as they used regular insulin before lunch, and 71.5% used basal-bolus insulin regimen. The mean percentage of insulin unites per Kg. was 1.00 + 0.38 U/kg./day. The mean BMI was = 24.54 + 6.42, while the BMI distribution was: 56% were with normal weight = < 25, 27% were overweight = 25: < 30, 14% were obese = 30: < 40 and only 3% were with severe obesity where BMI = > 40. The results showed also that 34.8% of the diabetic patients were doing continues home blood glucose monitoring with glucose sensors, 25.8% were doing the monitoring only with visual strips, while 39.4% of the diabetic children were not doing home monitoring at all. The study of control of diabetes showed that the glycated HbA Ic was < 7% in 31%, 7-8% in 22%, > 8-9% in 14% and > 9% in 33%. As regards the diabetic patients with ketoacidosis, 39% of them were diagnosed as the first presentation of diabetes. The duration required, for ketoacidosis, to be resolved was < 6 hr. in 44%, 6-12 hr. in 38.6%, > 12-24 hr. in 12.6%, and > 24% in only 3.8%. The results showed, also, that only 4.3% of DKA-cases were with PH < 7.0, 8.7% were with PH = 7: 7.1, 7.7% were with PH> 7.1: 7.2, 32.4% were with PH > 7.2: 7.3 and 7.2% only were with PH > 7.3. The above results showed also that 13.0% of ketotic cases were with severe acidosis, 7.7% were with moderate acidosis, and 32.4% were with mild acidosis. The discussion of these results documented that it will be essential to follow the international guidelines of management of type 1 diabetes and it was recommended to do proper diagnosis of different types ol diabetes among diabetic children and to study the prevalence anc incidence of diabetes among Egyptian children as the prevalent L and incidence still uncertain till now

Seguimiento prospectivo de una población infectada por VIH con y sin posibilidades de terapia anti retroviral: impacto en sobrevida y complicaciones / Prospective follow up of HIV positive patients with and without access to antiretroviral therapy: survival and complications

Background: Three-drug antiretroviral therapy (ART-3) has reduced complications and improved survival in HIV+ patients. The Chilean Public Health System began dual therapy (ART-2) in 1997, covering approximately 40 percent of patients in need. Aim: To report the results of a follow-up of patients with and without access to ART in a Chilean public hospital. Patient and Methods: Prospective follow-up of patients with ART-2 and 3 (cases) and patients with no access to ART (controls). All patients needed ART but it was available to a minority of them. Selection for ART was at random. Follow-up was between 6-24 months (11/96 to 3/99). Basal and periodic clinical and laboratory parameters were determined. Mortality and occurrence of new AIDS-defining events (ADE) were compared statistically using chi square. Results: One hundred and fifty cases (106 ART2, 28 ART3 and 16 ART2 expanded to ART3) and 166 controls were studied. Basal parameters were similar except prior ART (32.7 and 18.7 percent in cases and controls respectively). Close to 1/3 patients had AIDS. Cases had a mean follow up of 527 days; controls, 478. Six cases (4 percent) (5 in ART-2) and 17 controls (10 percent) died. Mortality x 100/pts/yr was 2.7 in cases and 7.7 in controls, p <0.05. ADE per 100/pts/yr was 21 in cases (24.4 in ART2, 15.1 in TAR3) and 54.5 in controls, p <0.05. Cases had a reduction of: esophageal candidiasis (84 percent), tuberculosis (75 percent), cryptococcosis and toxoplasmosis (66 percent), P carinii pneumonia (55 percent) and bacterial pneumonia (46 percent) and they had fewer hospitalizations (73 percent). Late assessment: 70 of 101 ART-2 patients had changed to ART-3 (1 death); 22 of 101 kept original ART-2 (12 dead, 10 alive), 39 of 43 ART-3 patients were alive and 1 died. Conclusions: Short-term ART-2 and 3 significantly reduced mortality (60 percent and 73 percent) ADE (65 percent and 76 percent respectively) and hospitalizations. Benefits of ART-2 were short lived. Resource-constrained countries cannot depend on weaker than standard ART for proper care of people with HIV disease

Examen del corazón / Examination of the heart

La literatura médica, y en particular la referida al área cardiovascular, ha contado con excelentes y brillantes aportes, tanto de autores extranjeros como nacionales. Hasta la década de los cincuenta, la semiología cardiovascular que se enseñaba y se prcticaba en nuestro país, era la de la escuela francesa, sitio donde se formaron nuestros maestros; y todavía recordamos la acuciosidad y la prolija metodología de ellos, cuando durante la revista a los pacientes hospitalizados, hacían un modesto alarde de sus facultades, y nos deslumbraban, con justa razón, de sus habilidades y conocimientos. El avance de la investigación tecnológica en los últimos años, con la aparición de novedosas técnicas, cada una de ellas más deslumbrantes, clarificantes por otra parte de una serie de hechos que desafían la capacidad de los sentidos, ha traído como consecuencia que nuestros estudiantes y profesionales, tengan tendencia a la apresurada y a veces innecesaria utilización de estos métodos, que siendo de indudable utilidad, no reemplazan ni sustituyen la información que puede ser suministrada por la juiciosa y adecuada aplicación de una semiología cardíaca, efectuada con constansia y aplicación, apoyados sobre conceptos fisiopatológicos, los cuales permiten ser corroborados posteriormente con la utilización de algunos de estos métodos, pero en forma alguna, acudir a ellos en una primera instancia, como elementos diagnóstico de primera opción, alejándose de la manera más elemental y afortunada de lo que constituye y representa el arte de la medicina