The development of the Delivery Assessment Tool (DAT) to facilitate quality improvement in burns services in low-middle income countries.

Implementation science is a useful tool to consider ways in which we can introduce improvements to burn services in low-and-middle income countries (LMICs), where the majority of the burden of burn injury is now experienced. This paper outlines the development of the Delivery Assessment Tool (DAT), a method for facilitating quality improvement in burn services in LMICs. We used a participatory approach that ensured that local clinicians and experts were fully involved in piloting the tool. The DAT is based on internationally agreed operational standards for burn care service delivery and has undergone an iterative process of improvement and refinement through an initial three-year project in Nepal and Bangladesh. The DAT, a 50-item tool organised into 10 subsections, is used to assess a service through a participatory focus group discussion with a mixed, multidisciplinary team of staff working at the burn service, typically 6-10 participants. This usually lasts 2-3 h. The staff in the unit then select priority areas for quality improvement programmes that are within their control to achieve, which starts a cycle of audit and review. The final version of the tool was used in a further three-year project to evaluate 11 hospitals in Nepal and Bangladesh. Education and training are key components of this work; both were provided by Interburns as part of on-going support for the clinical teams. At the end of the project a>19% improvement in scores was demonstrated using the final version of the DAT in both Nepal and Bangladesh; this achievement is remarkable given the continued difficulties in service provision where patient numbers far outstrip the resources available to care for them. As a result of this work, we have made a digital version of the tool available free of charge.

Visual loss and falls: a review.

Falls are an important health issue. They cause significant morbidity and mortality particularly in older people, and also have marked psychological effects on the individual. The literature focuses particularly on older adults, an age group in which both visual impairment and falls are more prevalent, as is the associated morbidity. In this review, we summarise the current literature and point to further studies which need to be undertaken. The consequences of falls are well recognised, and there has been considerable work into identifying risk factors. Changes in visual components such as visual field, acuity, contrast sensitivity and stereopsis all have a part and the co-existence of other sensory impairments certainly increases the risk of falls. However there remain considerable gaps in our knowledge of the relationship between visual loss and falls, for example in patients with diabetic eye disease. Furthermore, there is also conflicting data as to the importance of different visual components. Various interventions, such as programmed inter-disciplinary involvement, have shown promise, however these need further confirmation of their efficacy and cost effectiveness. An added confounder may be that an intervention (eg, cataract extraction) paradoxically affects an individual's future activity level and behaviour, thereby increasing the risk of falling. With an ageing population the importance of this topic is likely to increase, as will the potential benefits of optimising our assessment and management of these patients.

Effectiveness of structured teaching program in improving knowledge and attitude of school going adolescents on reproductive health.

INTRODUCTION: Development of knowledge and attitude takes place during the adolescent period, which can have lifelong effects on the individual, family and society. Proper education in this age group is important for prevention of untoward social and health related problems. OBJECTIVE: To find out the effectiveness of structured teaching program in improving knowledge and attitude of school going adolescents on reproductive health. MATERIALS AND METHODS: An experimental study with pretest - posttest control group design was carried out in four selected schools with similar settings in Dharan town of Nepal. All the subjects were divided into two groups: experimental and control, each comprising of two subgroups of 50 boys and 50 girls. Structured teaching program consisting of information on human reproductive system was used as a tool of investigation for the experimental group, whereas conventional teaching method was used for the control group. RESULTS: A total of 200 Adolescent school students were included in this study. The mean (+/-SD) pretest score of the experimental group on knowledge of reproductive health was 39.83 (+/- 16.89) and of the control group was 39.47(+/- 0.08). The same of experimental group after administration of the structured teaching program (84.60+/-10.60) and of the control group with conventional teaching method (43.93+/-10.08) was statistically significant (p<0.001). Similarly, the post-test scores of knowledge of the groups on responsible sexual behaviour and their attitude towards reproductive health were better in the experimental group than in the control group (p<0.001). CONCLUSION: The knowledge of adolescent school students on reproductive health is inadequate. The use of structured teaching program is effective in improving knowledge and attitude of the adolescents on reproductive health.

Nramp1 modulates iron homoeostasis in vivo and in vitro: evidence for a role in cellular iron release involving de-acidification of intracellular vesicles.

Nramp1 controls responses to infection and encodes a biallelic (G169D) macrophage-restricted divalent-cation transporter. Nramp1(D169) is phenotypically null. We demonstrate Nramp1 is implicated in iron regulation in vivo. In spleen, expression is exclusive to Nramp1(G169) strains within the red pulp. By morphometric analysis, the distribution of splenic iron, following systemic overload, correlates with Nramp1 genotype. More iron is located within the red pulp in Nramp1(D169) strains, whereas in Nramp1(G169) strains iron deposits are localized within the marginal-zone metallophilic cells. Nramp1 immunoreactive protein is not present in control brain, but inducible within a hemorrhagic lesion model in Nramp1(G169) strains. Nramp1 protein expression demonstrates an inverse correlation to the presence of iron. Nramp1(G169) strains show no Perl's stain-reactive iron within the lesion. In contrast, Nramp1(D169) strains display iron-staining cells. The process of cellular iron regulation was investigated in vitro in Nramp1(G169) transfectant Raw264.7 macrophages. Greater (30-50%) iron efflux from Nramp1(G169) compared with Nramp1(D169) cells was determined. The extent of Nramp1-dependent iron-release was influenced by bafilomycin A1, and endogenous nitric oxide synthesis, both inhibitors of vacuolar-ATPase. This study demonstrates that Nramp1 regulates macrophage iron handling, and probably facilitates iron release from macrophages undergoing erythrophagocytosis in vivo.