Non-invasive ventilation for children with acute respiratory failure in the developing world: literature review and an implementation example.

Over 2 million children die of acute respiratory infection every year, with around 98% of these deaths occurring in developing countries. Depending upon the clinical status of the patient, supplemental oxygen is usually the first line therapy. However this often proves inadequate for acute respiratory failure (ARF), in which case intubation and mechanical positive pressure ventilation are required. Adult intensive care successfully introduced non-invasive positive pressure ventilation (NIPPV) to treat ARF over a decade ago. This experience, coupled with the use of NIPPV in children with chronic respiratory insufficiency, has led to increasing use of NIPPV to treat ARF in paediatric populations. NIPPV can have similar or improved outcomes to IPPV, but with fewer complications. However there are no controlled trials of its use in children, and most data come from observational studies and retrospective reviews. In a developing world setting, where mortality from ARF is high and the risks of intubation are great and often not feasible, NIPPV can be a simple and cost-effective way to treat these patients. Its implementation in rural Northern Ghana shows NIPPV for ARF can be delivered safely with minimal training, and appears to impact significantly on mortality in those under 5 years.

Demographic, clinical features and treatment outcomes in 700 achalasia patients in iran.

BACKGROUND Achalasia is the most recognized motor disorder of the esophagus. Because it is an uncommon disease, most studies have reviewed small numbers of patients. Here, we report demographic, clinical features and treatment outcomes in 700 achalasia patients. METHODS In all patients, diagnosis was established based on clinical, radiological, endoscopic and manometric criteria. A questionnaire was completed for each patient and included the patient's age, gender, initial symptoms, frequency of different symptoms, presence of positive family history for achalasia, other accompanying diseases and treatment outcomes. RESULTS In our study men were affected more than women (54.3% vs. 45.7%). Patients' mean age was about 38 years. The most frequent symptoms noted were: dysphagia to solids and liquids, active regurgitation, passive regurgitation and weight loss, respectively. Women complained of chest pain more than men (59% vs. 47.1%, p=0.04). The vast majority of our patients were treated by pneumatic dilation (PD) of the LES and in long-term follow-up, 67% were in the responder group. Females responded better than males to PD. CONCLUSION Dysphagia to solids is the most common symptom in patients with achalasia. Chest pain was significantly higher among women. PD is an effective treatment for achalasia with long-term efficacy in the majority of patients.

R632W mutation in PLA2G6 segregates with dystonia-parkinsonism in a consanguineous Iranian family.

BACKGROUND: PLA2G6 mutations are known to be responsible for infantile neuroaxonal dystrophy (INAD) and neurodegeneration with brain iron accumulation (NBIA). In addition, novel mutations in PLA2G6 have recently been associated with dystonia-parkinsonism in two unrelated consanguineous families. METHODS: Direct sequencing analysis of the PLA2G6 gene. RESULTS: Here, we report the segregation of R632W with disease in an Iranian consanguineous dystonia-parkinsonism pedigree. The identical mutation was previously observed in a patient affected with NBIA. CONCLUSION: We conclude that different and even identical PLA2G6 mutations may cause neurodegenerative diseases with heterogeneous clinical manifestations, including INAD, NBIA and dystonia-parkinsonism.

Bioemulsifier production by a halothermophilic Bacillus strain with potential applications in microbially enhanced oil recovery.

A halothermotolerant Gram-positive spore-forming bacterium was isolated from petroleum reservoirs in Iran and identified as Bacillus licheniformis sp. strain ACO1 by phenotypic characterization and 16S rRNA analysis. It showed a high capacity for bioemulsifier production and grew up to 60 degrees C with NaCl at 180 g l(-1). The optimum NaCl concentration, pH and temperature for bioemulsifier production were 4% (w/v), 8.0, and 45 degrees C, respectively. Although ACO1 did not utilize hydrocarbons, it had a high emulsifying activity (E (24) = 65 +/- 5%) on different hydrophobic substrates. Emulsification was optimal while growing on yeast extract as the sole carbon source and NaNO(3) as the nitrogen source. The efficiency of the residual oil recovery increased by 22% after in situ growth of B. licheniformis ACO1 in a sand-pack model saturated with liquid paraffin.

A simplified technique of ptosis repair using a single adjustable suture.

PURPOSE: To describe a simplified technique for ptosis repair using a single adjustable suture. DESIGN: Retrospective noncomparative series. PARTICIPANTS: Fifty-one cases of ptosis repair performed or supervised by the same surgeon between 1993 and 1995. INTERVENTION: The surgical approach consisted of using a single adjustable "hang-back" 5-0 silk suture for plication of the superior portion of the levator aponeurosis. Lid height was then reassessed within the first 4 postoperative days and permanently readjusted by fixating the adjustable suture. Excluded were patients with history of unstable ptosis as a result of systemic disease or congenital, mechanical, and traumatic ptosis resulting from a mass or trauma. The follow-up period ranged from 3 to 31 months. MAIN OUTCOME MEASURE: Lid position. RESULTS: All eyelids included in this study were corrected to 1 mm of the desired result. There were no incidents of peaking or recurrence on long-term follow-up. Complications included one case of hematoma and a case of slight tenting of the eyelid margin. CONCLUSIONS: This procedure combines the physiologic approach of levator aponeurosis surgery with the simplicity and flexibility of a single adjustable "hang-back" type suture. It may readily be combined with other procedures such as blepharoplasty. It is also useful when the "ideal" lid level may not be determined until the postoperative period, such as eyes subject to ptosis by Hering's law, levator dehiscence, or those at increased potential risk for corneal exposure.

High-performance liquid chromatography method for the quantification of non-radiolabelled cinnamic compounds in analytes derived from human skin absorption and metabolism experiments.

An isocratic high-performance liquid chromatography method has been developed for the quantification of the skin sensitisers trans-cinnamaldehyde and trans-cinnamic alcohol, and their cinnamic metabolites. The relative standard deviations (RSDs) between the gradients of eight sets of standard curves were 2.8, 3.1 and 1.9% for cinnamic alcohol, cinnamaldehyde and cinnamic acid, respectively. Sample analytes were derived from two series of experiments: in vitro full-thickness human skin absorption and metabolism studies and metabolism studies using human skin homogenates, with non-radiolabelled cinnamic compounds. Skin absorption and metabolism experiments were performed in the absence and presence of the alcohol dehydrogenase inhibitor, pyrazole. Samples from full-thickness skin absorption studies were analysed without extraction; cinnamic compounds from within skin were extracted into methanolic solutions using newly developed methods. The intra-assay RSDs ranged from 0.17 to 2.52% for cinnamic alcohol, 0.24 to 9.14% for cinnamaldehyde and 0.26 to 6.43% for cinnamic acid. The inter-assay RSDs for cinnamic alcohol, cinnamaldehyde and cinnamic acid, respectively, as determined from n=20 HPLC runs, were 2.10, 4.16 and 2.26%.

Human skin absorption and metabolism of the contact allergens, cinnamic aldehyde, and cinnamic alcohol.

trans-Cinnamaldehyde and trans-cinnamic alcohol have been commonly reported to cause allergic contact dermatitis (ACD) in humans. Cinnamaldehyde is a more potent skin sensitizer than cinnamic alcohol. It has been hypothesized that cinnamic alcohol is a "prohapten" that requires metabolic activation, presumably by oxidoreductase enzymes such as alcohol dehydrogenase (ADH) or cytochrome P450 2E1 (CYP2E1), to the protein-reactive cinnamaldehyde (a hapten). In this study, the in vitro percutaneous absorption and metabolism of cinnamaldehyde and cinnamic alcohol (78 micromol dose) has been examined using freshly excised, metabolically viable, full-thickness breast and abdomen skin from six female donors. Penetration rates and total cumulative recoveries of cinnamic compounds that were present in receptor fluid, extracted from within the skin, evaporated from the skin surface, or remained unabsorbed on the skin surface after 24 h were quantified by reversed-phase high-performance liquid chromatography. Biotransformation of cinnamaldehyde to both cinnamic alcohol and cinnamic acid was observed. Topically applied cinnamic alcohol was converted to cinnamaldehyde (found on the skin surface only) and cinnamic acid. To establish whether these biotransformations were enzymatic, experiments were performed in the absence and presence of varying concentrations (80-320 micromol) of the ADH/CYP2E1 inhibitors pyrazole or 4-methylpyrazole. The observation that pyrazole significantly reduced (p < 0.05) the total penetration of cinnamic metabolites into receptor fluid, following either cinnamaldehyde or cinnamic alcohol treatment, but did not significantly affect parent chemical penetration, suggests that we are measuring cutaneous metabolic products of ADH activity. The skin absorption and metabolism of cinnamaldehyde and cinnamic alcohol will play an important role in the manifestation of ACD following topical exposure to these compounds.

Lower eyelid hernia repair for palpebral bags: a comparative study.

The standard treatment for herniated "bags" of the lower eyelid is surgical removal of excess fat. Sachs and Bosniak in 1986 and de la Plaza and Arroyo in 1988 described a new technique for treatment of palpebral bags that consisted of returning the herniated fat to the orbital cavity and retaining it by continuous sutures of the capsulopalpebral fascia either to the dehiscent portion of the orbital septum or to the periosteum of the lower orbital rim. This article reports a prospective study of 26 patients who underwent standard blepharoplasty in one lower eyelid and capsulopalpebral fascia hernia repair in the other lower eyelid. All were evaluated at 6 weeks and at 6 months after surgery, and the outcomes were compared. The results of the two different techniques in the same patient have shown comparable aesthetic outcomes in the treatment of palpebral bags. However, results indicate that the capsulopalpebral fascia hernia repair technique carries less discomfort and pain during the operation and may be less prone to postoperative bleeding and hematoma formation. In addition, in contrast to standard lower blepharoplasty with fat resection, hollowing of the lower lid or potential sunken appearance of the globe may remain absent with capsulopalpebral fascia hernia repair beyond the 6-month period of this study.

Experience and acceptability of emergency hormonal contraception.

Objective: The study was designed to evaluate the experience and acceptability of emergency hormonal contraception service for inner-city women in Planned Parenthood clinics.Methods: In 1995, emergency hormonal contraception was introduced as a new service in three clinics of New York City's Planned Parenthood that served low-income women. Shortly after inception of this service, the agency undertook a survey to investigate patient experience and acceptability of the service. The survey addressed side effects and patients attitudes about emergency hormonal contraception. It also addressed suggestions for improving the service.The indication for the use of this method was unprotected intercourse within the previous 72 hours of first dosage of certain birth control pills. We used Lo/Ovral (norgestrel 0.3 mg + ethinyl estradiol 30 µg) 4 tablets given stat and second dose 12 hours later.Results: There were 118 patients who responded to the survey. The average patient age was 25 years. Approximately half of the women were white and half were other. The majority were nulliparous, and 42% had one or more abortions in the past. Side effects such as nausea, vomiting, and fatigue and their prevalence were noted. Two women reported method failure. Both patients elected abortion. The vast majority (92%) stated that they would use the method again. Patients also made several recommendations for enhancing the service.Conclusion: As a result of this survey, Planned Parenthood of New York City completely revised its emergency hormonal contraception protocols in order to increase patient satisfaction while maintaining high medical standards to ensure lower method failure and drug side effects in more than 1,000 patients so far.

"Pneumofornix" (air under the eyelid): a normal finding.

Normal pockets of air under the eyelids have not been previously described in the literature. To assess the incidence and patterns of normal air bubbles in the region of the eyelid, computed tomography (CT) scans of 126 normal orbits and 36 orbits of patients with thyroid orbitopathy were assessed. Twenty-eight (22%) of the normal orbits and 14 (39%) of the thyroid orbits had a well-defined medial or lateral air bubble (or both) on axial views (.1 > P > .05). Oval central or paracentral air bubbles in sections through the superior or inferior fornix were seen in 19 (15%) of the normal orbits and 10 (28%) of the thyroid orbits (.1 > P > .05). It is important to be aware of the incidence and patterns of these normal air bubbles to ensure their accurate differentiation from pathologic air bubbles.

Abortion education for residents.

Planned Parenthood of New York City established a physician education program in first-trimester abortion using local anesthesia at its three clinics. This paper describes the program's technical and counseling skills curricula, individualized instruction, quality-assurance procedures, obstacles encountered, and solutions implemented. Major obstacles were slow initial recruitment, disincentives of off-site education, and scheduling difficulties. Solutions included grand rounds presentations at local hospitals to recruit residents, considerable flexibility in rotational scheduling, and expansion of instructional staff to include academic physicians as teachers. Since its inception in July 1993, 53 residents and attending physicians have been taught to perform induced abortions at Planned Parenthood, and 25 who completed the program are currently providing abortions around the nation. Planned Parenthood's experience in teaching residents from local hospitals to perform first-trimester abortion using local anesthesia may be valuable for those who wish to implement similar collaborative off-site educational programs.

Derivatization with monomethoxypolyethylene glycol of Igs expressing viral epitopes obviates adjuvant requirements.

Ig molecules expressing within the CDR3 loop viral B or T cell epitopes were derivatized with mPEG 5,000. Pegylated Ig were used to investigate the in vitro and in vivo effect of pegylation on the immunogenicity of viral epitopes expressed in chimeric Ig. Two chimeras were used in this study: Ig-HA carrying a CD4 epitope corresponding to amino acid residues 110-120 of the hemagglutinin (HA) of PR8 influenza A virus and Ig-V3C, a murine-human chimera carrying a consensus B cell epitope from the V3 loop of HIV-1 gp120 protein. Pegylated Ig-HA (Ig-HA-mPEG) with 6 to 8% substituted lysine residues showed in vivo resistance to enzymatic degradation and persisted significantly in blood circulation and lymphoid organs. Moreover, Ig-HA-mPEG was able to activate in vitro HA110-120-specific hybridoma T cells and to prime T cell proliferative response in vivo without requirement for adjuvant. Also, mildly pegylated Ig-V3C (Ig-V3C-mPEG) administered into BALB/c mice in the absence of adjuvant induced specific Ab response to V3C peptide with insignificant response to xenogeneic human Ig determinants.

Antibody response elicited by T-dependent and T-independent antigens in gene targeted kappa-deficient mice.

Animal models substantially contribute to the understanding of the pathogenesis of various human diseases, including those associated with genetic defects. Our study investigated the characteristics of antibody responses elicited by T-dependent and T-independent antigens in mice rendered kappa-deficient by targeted deletion of the J kappa C kappa gene segments. It is known that in normal murine species the kappa repertoire dominates the antibody repertoire (kappa/lambda ratio = 95:5). Our results indicate that the kappa gene deletion causes the alternative usage of lambda 1 (93%) and lambda 2 (7%) light chains, confirming previous studies demonstrating that in kappa-deficient mice all B cells express Ig lambda receptors. The anti-trinitrophenylbenzene (TNP) response in K-/- mice was compensated for by lambda 1 and lambda 2 bearing Igs. However, isoelectric focusing analysis of anti-TNP antibodies showed a considerably more restricted pattern of lambda anti-TNP antibodies in K-/- as compared with kappa antibodies in normal mice. No major differences were observed in the affinity for the hapten of kappa or lambda 1 or lambda 2 mAbs obtained from 129/Sv and K-/- mice. Furthermore, lambda 1 and lambda 2 chains can reconstitute the expression of an idiotype (460Id) borne on kappa anti-TNP antibodies. The 460Id was detected both in polyclonal and monoclonal anti-TNP antibodies obtained from K-/- mice. Our results clearly showed that the kappa anti-TNP repertoire is compensated by the lambda repertoire even though the latter is clonally restricted in K-/- mice.

Contraception for the disabled.

PIP: The obstetrician-gynecologist clinic should provide easy access for the disabled patient such as a hydraulic pelvic examination table. In most cases, disability does not affect sexuality, menstruation, or fertility but may change the level of interest and activity. Thus the physician should include sexual counseling even for abled patients with disabled partners. He/she should document the informed consent process to make sure it is legal and ethical. He/she must do a thorough evaluation of each disabled patient and her needs and develop a special protocol for each patient. The physician must know those disabled conditions that limit pelvic examination ability an contraindicate some contraceptives. Oral contraceptives (OCs) and progestin implants are contraindicated in women with spinal cord injury (SCI), disabled by a stroke, and with neurologic disorders that inhibit mobility in the lower extremities and cause circulatory disorders. Depending on individual circumstances, physicians should not advise OC use for women who are mentally retarded, mentally ill, or are drug abusers since they either do not understand, cannot remember, or are not motivated to take OCs regularly. Progestin implants may be a viable option for drug abusers, the mentally ill, and mentally retarded women. Once the US Food and Drug Administration approves injectable progestational agents, they could be another option for these women. The IUD is contraindicated in women who have no sensory capabilities and could not notice an ectopic pregnancy and pelvic infection. This may include women with some neurologic disorders, stroke, SCI, and multiple sclerosis. It is also contraindicated in women who have a blood disease, use anticoagulants, or have AIDS. Barrier methods could be used if a disabled patient or a partner is able to put them in place. In some cases, sterilization may be justified on medical grounds.^ieng

Complications of first-trimester abortion: a report of 170,000 cases.

One hundred seventy thousand first-trimester abortions were performed in three free-standing clinics of Planned Parenthood of New York City from 1971-1987. Seventy percent of the procedures were done under local anesthesia; the remainder under intravenous methohexital. No preoperative medications or routine postoperative antibiotics were given. High-risk patients were referred to a hospital. The clinics operated under uniform written guidelines. Experienced physicians performed the procedures. There were no deaths in this series of patients. One hundred twenty-one patients were hospitalized (0.71 per 1000) for suspected perforation, ectopic pregnancy, hemorrhage, sepsis, or recognized incomplete abortion. There was no major extirpative surgery performed. There were an additional 1438 minor complications (8.46 per 1000). Overall, there were 9.05 complications per 1000 abortions. The complication rates for procedures done under general anesthesia and local anesthesia were similar. We conclude that outpatient abortion on selected patients to the 14th week from the last menstrual period is a safe procedure.