Increasing the exclusive breastfeeding rate in a private hospital in UAE through quality improvement initiatives.

BACKGROUND: Mother's milk is the best, and ideal method for infant feeding. We found that this practice was not being followed in our hospital. A survey was conducted in the unit with regards to breastfeeding practices which revealed that most babies who were discharged from our nursery were on formula supplements. Our goal was to improve established breastfeeding rates in the unit by increasing the number of full-term healthy babies who were discharged on exclusive Breastfeeding. METHOD: A project team was formed, and data were collected through direct observations and direct interviews with postnatal mothers. Exclusive Breastfeeding at discharge was defined as a baby being fully on breastfeed with no additional formula supplements for at least 12 hours prior to discharge. The primary outcome was to increase the percentage of babies being discharged on exclusive Breastfeeding. We used the FOCUS PDCA model to measure improvements and 8 PDCA cycles of 4 weeks duration were implemented to test the changes. RESULTS: The interventions we put in place led to a considerable nine times overall improvement in the established breastfeeding rates. Among all the interventions, the most promising results were observed during the PDCA cycles involving staff education, the introduction of antenatal classes for mothers, skin to skin contact and rooming in. CONCLUSION: Breastfeeding rates in the private sector with nursery services can be improved by reinforcing breastfeeding education for mothers in addition to training the maternal care staff, empowering them to promote and assist in breastfeeding.

Level III dissection in locally advanced breast cancer following neoadjuvant chemotherapy: a retrospective study.

INTRODUCTION: Breast cancer is the most common female cancer in India, and 30-60% of patients present with locally advanced breast cancer. Level III clearance is routinely performed in India in locally advanced breast cancer following neoadjuvant chemotherapy, even in clinical complete response. We analysed our data of patients with locally advanced breast cancer post-neoadjuvant chemotherapy who have undergone level III clearance to identify any subgroup in which level III dissection can be avoided. MATERIAL AND METHODS: This is a retrospective study of female patients with locally advanced breast cancer who received neoadjuvant chemotherapy and underwent breast surgery including level III nodal clearance between June 2016 and May 2018. Data collected included age, menopausal status, TNM stage at presentation, grade, estrogen, progesterone, human epidermal growth factor receptor 2 status, response to treatment, post-chemotherapy stage and final histopathology. Uni- and multivariate analysis was undertaken. RESULTS: Data from 200 patients was analysed. The level III positivity rate was 15.5%. The clinical complete response rate was 43%, of which 41% had pathological complete response. A significant association was present between level III node positivity and pathological T stage (p=0.03). No association was seen between level III positivity and any other studied variables. In the subset of patients with cT3N1 and cT2N2, level III positivity was seen in only 3/49 (6.1%) and 1/31 (3%), respectively. CONCLUSION: Level III positivity rate is high and so cannot be avoided in locally advanced breast cancer following neoadjuvant chemotherapy. None of the preoperative factors predict for level III positivity. Level III positivity in cT3N1 and cT2N2 is low and these subgroups require further studies.

Pancreas size and exocrine function is decreased in young children with recent-onset Type 1 diabetes.

AIMS: To measure pancreatic area and exocrine function in young children with recent-onset Type 1 diabetes to determine whether the exocrine pancreas is also affected in the pathophysiology of early childhood diabetes. METHODS: Thirty-two children (14 boys) aged 5.5 (4.5, 7.3) median (IQR) years presenting with recent-onset Type 1 diabetes and 90 controls (44 boys) of similar age had ultrasound imaging of the pancreas. Children with Type 1 diabetes were receiving insulin and were without ketosis. Transverse and longitudinal areas of the pancreas were measured by digitalized outline. Pancreatic faecal elastase-1 was analysed using an enzyme-linked immunosorbent assay kit in recent-onset Type 1 diabetes and 38 first-degree relative control children. RESULTS: Pancreatic area and exocrine function were reduced in Type 1 diabetes. Mean transverse area (SD) in Type 1 diabetes was 6.82 cm2 (1.61) vs. 8.31 cm2 (1.74) in controls, adjusted estimate (95% CI) 1.45 (-2.12, -0.79), P < 0.001; longitudinal area was 1.28 cm2 (0.44) vs. 1.55 cm2 (0.43), adjusted estimate (95% CI) -0.27 (-0.45, -0.09), P = 0.003. Faecal elastase-1 levels in Type 1 diabetes were 455 (323, 833) ug/g, median (IQR) vs. 1408 µg/g (1031, 1989) in controls, P < 0.001. CONCLUSION: Pancreatic area and accompanying subclinical exocrine function were reduced in very young children with recent-onset Type 1 diabetes. This supports changes in the exocrine pancreas in the pathophysiology of Type 1 diabetes presenting in early life.

Physicians' Opinions on Engaging Patients' Religious and Spiritual Concerns: A National Survey.

CONTEXT: There has been a sustained debate in the medical literature over whether physicians should engage with patients' religious and spiritual concerns. OBJECTIVES: This study explores what physicians believe about the relative importance and appropriateness of engaging with patients' spiritual concerns and physicians' choices of interventions. METHODS: In 2010, a questionnaire was mailed to 2016 U.S. physicians with survey items querying about the relative importance of addressing patients' spiritual concerns at the end of life and the appropriateness of interventions in addressing those concerns. The survey also contained an experimental vignette to assess physicians' willingness, if asked by patients, to participate in prayer. RESULTS: Adjusted response rate was 62% (1156/1878). The majority of physicians (65%) believe that it is essential to good practice for physicians to address patients' spiritual concerns at the end of life. Physicians who were more religious were more likely to believe that spiritual care is essential to good medical practice (odds ratio: 2.76, 95% CI 1.12-6.81) and believe that it is appropriate to always encourage patients to talk to a chaplain (odds ratio: 5.71, 95% CI: 2.28-14.3). A majority of the physicians (55%) stated that, if asked, they would join the family and patient in prayer. Physicians' willingness to join ranged from 67% when there was concordance between the physician's and the patient's religious affiliation to 51% when there was discordance. CONCLUSION: The majority of U.S. physicians endorse a limited role in the provision of spiritual care, although opinions varied based on physicians' religious characteristics.

Anorectal melanoma: experience from a tertiary cancer care centre in South India.

Introduction Mucosal malignant melanoma of the anorectum is a rare and aggressive disease, in which early diagnosis is difficult. The prognosis remains extremely poor, irrespective of the treatment. We share our experience in treating this malignancy at our centre in South India. Methods This study describes a retrospective analysis of 31 cases of anorectal melanoma presented to our centre between January 2001 and December 2013. Results Twenty-two patients (71%) presented with metastasis and had a median overall survival of nine months. None of the 22 patients survived for two years. Nine patients (29%) had curative surgery, in the form of abdominoperineal resection (six patients), abdominoperineal resection with bilateral inguinal node dissection (one patient), abdominoperineal resection with liver resection (one patient) and posterior exenteration (one patient). In patients who underwent curative surgery, the median overall survival was 15 months and disease-free survival was nine months, with a two-year overall survival of 22%. Conclusions Anorectal melanoma is an aggressive disease with a poor prognosis. The majority of patients present with distant metastases. Prognosis depends on stage at presentation. Early diagnosis and surgical resection may improve the overall outcome. Newer modalities such as immunotherapy and targeted therapies such as anti-CTLA4 monoclonal antibody and anti-programmed cell death protein 1 monoclonal antibodies have radically changed the management of mucosal melanoma and may, in the future, improve the overall prognosis of anorectal melanoma.

Factors affecting health related quality of life of rectal cancer patients undergoing surgery.

Maintaining quality of life (QOL) is one of the important aims of cancer treatment. Quality of life of a cancer patient is affected by various factors, which may be disease related, patient related, or treatment related. To study changes in health-related quality of life (HRQOL) brought about by treatment of rectal cancer and factors affecting the changes using Malayalam translation of FACT-C (Functional Assessment of Cancer Therapy-Colorectal) Questionnaire. Also to detect the minimally important clinical changes (MICC) in health-related quality of life of patients with carcinoma rectum, who have undergone surgery. Forty-five patients diagnosed with carcinoma rectum, who have undergone curative surgery, were studied. HRQOL was assessed at baseline 2 weeks after surgery and 3 months after surgery. The changes in scores were correlated with various demographic factors like age, sex, marital status, number of children, number of married children, and education and occupation of the patient and spouse. Also the treatment-related factors like presence of stoma, presence of morbidity, previous treatment, stage of disease, and administration of chemotherapy before and after surgery were correlated. All the subscales of FACT-C tool, except emotional well-being, were significantly reduced 2 weeks after surgery and increased slightly above pre-treatment level 3 months after surgery. The Chronbach α values were 0.88, 0.89 and 0.86 on three occasions, respectively, establishing internal validity of the test. Baseline HRQOL scores were better in males compared to females. Among the various subscales, the drops in SWB, FWB, FACT-G, total Score and TOI were significant (P < .05).There were no significant differences in scores between patients who have undergone open surgery and minimally invasive surgery or patients who had permanent colostomy versus no colostomy. The HRQOL scores after surgery reduced 2 weeks after surgery and improved above pre-surgical levels 3 months after surgery. The approach of surgery (minimally invasive versus open) or presence or absence of permanent colostomy didn't make any significant change in HRQOL. But since the sample size of the study was small, we need further larger studies to arrive at definite conclusions.

Effect of shilajit on the heart of Daphnia: A preliminary study.

Shilajit is a mineral-rich complex organic compound used in the traditional system of Ayurvedic medicine for treating hypertension and improving the cardiac function with many herbomineral preparations. However, very little experimental evidence is available about its effect on the cardiac function. We used Daphnia as a model organism for observing the effect of shilajit on its heart due to its myogenic properties and its response to number of cardioactive drugs that are known to affect human heart function. Genome of Daphnia shows the strongest homology with the human genome. These characteristics of Daphnia make it an ideal organism for biomedical research. Our results suggest that this complex organic compound lowers the heart beats as its concentration increases from 1.0 to 100 ppm. The beats come to near normal condition at 1000 ppm. Above 1000 ppm, the beats are very fast and impossible to count. These results indicate a negative chronotropic effect on the Daphnia heart at low concentrations and a positive chronotropic effect to arrhythmia and finally failure at increasing higher concentrations of shilajit.

Voltammetric studies of sparfloxacin and application to its determination in pharmaceuticals.

A detailed study of the electrochemistry of sparfloxacin at a glassy carbon electrode was carried out in the pH range 2.0-10.0 in aqueous solution using cyclic and differential pulse voltammetry. Influence of different supporting electrolytes, pH, scan rate and concentrations were studied on the voltammetric response. The studies revealed the irreversible oxidation of sparfloxacin at basic pH in a diffusion controlled manner. In addition, a differential pulse voltammetric method was proposed for the determination of the drug in different pharmaceutical formulations.

Multidisciplinary approach in the long-term management of intrahepatic stones: Indian experience.

BACKGROUND: Intrahepatic stones, though common in East Asia, are uncommon in India. There is paucity of data from India regarding the treatment and long-term outcome of patients with intrahepatic stones. METHODS: We retrospectively analyzed medical records of 35 patients with intrahepatic stones who had been treated surgically. Endoscopic biliary drainage had been used in patients who presented with acute cholangitis. Intraoperative stone clearance was confirmed by choledochoscopy and intraoperative cholangiography. Outcome of surgery, frequency and subsequent management of recurrent intrahepatic stones, and factors associated with stone recurrence and cholangitis were analyzed. RESULTS: Twenty-one (60%) patients had bilobar disease. Eight patients underwent hepatectomy and 16 hepatico-jejunostomy with access loop; 12 of these were jejuno-duodenal anastomoses. Postoperative morbidity was observed in 10 patients (29%). Recurrence of stones occurred in 12 patients (34%) and cholangitis in 9 patients (26%). Presence of bilobar disease and associated biliary strictures were associated with recurrent cholangitis (p< 0.05). Two patients (6%) required re-operation for recurrent cholangitis. Complete removal of recurrent stones using conventional endoscope was possible through jejuno-duodenostomy in all 5 cases who had this type of access loop construction. CONCLUSION: Surgical treatment for intrahepatic stones depends on the site of involvement. Construction of a jejuno-duodenal access loop in patients with bilobar disease and intrahepatic strictures is helpful in facilitating postoperative stone clearance. A multidisciplinary approach is beneficial especially when the disease is bilobar and recurrent in type.

The effect of dietary betaine on intestinal and plasma levels of betaine in uninfected and coccidia-infected broiler chicks.

Chicks fed betaine supplemented diets and infected with Eimeria acervulina and Eimeria maxima had markedly higher levels of betaine in the duodenum and mid-gut than unsupplemented, infected chicks. Uninfected chicks fed betaine exhibited almost twice the levels of betaine in the gut as infected chicks. Plasma betaine levels were lower in E. maxima-infected chicks than in E. acervulina-or Eimeria tenella-infected chicks. Betaine supplementation reversed the decrease in weight gain in E. maxima- infected chicks but had no effect on the decrease in weight gains in E acervulina- and E. tenella-infected chicks. Coccidia-infected birds on normal diets regularly exhibit increases in plasma NO(2)(+)NO(3). This increase was abolished in E.tenella-infected birds on betaine supplement. Betaine feeding did not alter this effect in E. acervulina- and E. maxima-infected birds. Results indicate that betaine supplementation has a positive effect on gut betaine levels in birds infected with E. acervulina and E. maxima. In all treatment groups, infection lowered the levels of betaine.

Elevation of muscle and plasma 3-methylhistidine as a result of turkey coccidiosis.

To assess muscle breakdown during avian coccidiosis, the level of the non-metabolizable amino acid 3-methylhistidine (3MH) was determined in muscle and plasma from turkey poults that received an infection with a field isolate containing a mixture of Eimeria species. The effect of increased levels of parasitism was evaluated at 6 days postinoculation (DPI) in birds receiving 2.5 x 10(4), 1 x 10(5), or 2 x 10(5) oocysts each. The changes in 3MH levels during recovery from acute infection were assessed at 6-29 DPI in animals given 1.9 x 10(5) oocysts per bird. In some experiments, uninoculated birds given the same amount of feed as infected birds (pair fed) were used to determine the impact of feed deprivation on weight loss and 3MH levels. Infected birds had significantly elevated plasma and muscle 3MH at 6 DPI after a single dose of Eimeria oocysts. The plasma and muscle 3MH returned to control levels after 14 DPI. The 3MH levels increased with increased dose of oocysts. Plasma and muscle 3MH levels were well correlated, and an inverse curvilinear relationship between weight gain and plasma 3MH concentrations levels was observed. Plasma and muscle 3MH levels were significantly elevated in pair-fed birds, but 3MH levels in infected birds were increased by 30% over pair-fed birds. The results suggested that muscle breakdown, as assessed by plasma and muscle levels of 3MH, increased during the acute stage of Eimeria infection in turkey poults.

Eimeria adenoeides sporozoites: enhanced invasion of cultured cells previously inoculated with Eimeria acervulina sporozoites.

The effects of prior or concurrent administration of Eimeria acervulina on invasion of cultured cells by Eimeria adenoeides sporozoites and possible mechanisms of action were examined. Baby hamster kidney (BHK) cell cultures that were inoculated with E. acervulina sporozoites were significantly more permissive for invasion by E. adenoeides sporozoites than uninoculated cultures. Enhancement of invasion by E. adenoeides did not occur when the two species were inoculated into cultures concurrently, or within 30 h of each other. However, 48 and 72 h after inoculation of BHK cells with E. acervulina, invasion by E. adenoeides sporozoites was significantly greater than invasion in uninoculated cultures. At 96 h postinoculation with E. acervulina, the enhancing effect on invasion was variable. Culture media collected from E. acervulina-inoculated cultures also significantly enhanced invasion by E. adenoeides. Slight changes in proteins of E. acervulina-inoculated versus uninoculated cell cultures were detected by Western blots of biotinylated and nonbiotinylated cells. Biotinylated bands between 10 and 25 kDa increased in the inoculated cultures. In addition, when chicken anti-E. acervulina sporozoite serum was used as a probe, labeling of a 10 kDa antigen increased in the inoculated cultures.

Cell: sporozoite interactions and invasion by apicomplexan parasites of the genus Eimeria.

The site specificity that avian Eimeria sporozoites and, to a more limited degree, other apicomplexan parasites exhibit for invasion in vivo suggests that specific interactions between the sporozoites and the target host cells may mediate the invasion process. Although sporozoite motility and structural and secreted antigens appear to provide the mechanisms for propelling the sporozoite into the host cell,there is a growing body of evidence that the host cell provides characteristics by which the sporozoites recognise and interact with the host cell as a prelude to invasion. Molecules on the surface of cells in the intestinal epithelium, that act as receptor or recognition sites for sporozoite invasion, may be included among these characteristics. The existence of receptor molecules for invasion by apicomplexan parasites was suggested by in vitro studies in which parasite invasion was inhibited in cultured cells that were treated with a variety of substances designed to selectively alter the host cell membrane. These substance included cationic compounds or molecules, enzymes that cleave specific linkages, protease inhibitors, monoclonal antibodies, etc. More specific evidence for the presence of receptors was provided by the binding of parasite antigens to specific host cell surface molecules. Analyses of host cells have implicated 22, 31, and 37 kDa antigens, surface membrane glycoconjugates,conserved epitopes of host cells and sporozoites, etc., but no treatment that perturbs these putative receptors has completely inhibited invasion of the cells by parasites. Regardless of the mechanism,sporozoites of the avian Eimeria also invade the same specific sites in foreign host birds that they invade in the natural host. Thus, site specificity for invasion may be a response to characteristics of the intestine that are shared by a number of hosts rather than to a unique trait of the natural host. Protective immunity elicited against avian Eimeria species is not manifested in a total blockade of parasite invasion. In fact, the effect of immunity on invasion differs according to the eliciting species and depends upon the area of the intestine that is invaded. Immunity produced against caecal species of avian Eimeria, for example Eimeria tenella and Eimeria adenoeides, inhibits subsequent invasion by homologous or heterologous challenge species, regardless of the area of the intestine that the challenge species invade. Conversely, in birds immunised with upper intestinal species, Eimeria acervulina and Eimeria meleagrimitis, invasion by challenge species is not decreased and often is significantly increased.

Chasing coccidia--new tools enter the race.

The 8th International Coccidiosis Conference, held on 9--13 July 2001 in Palm Cove, Australia, was a showcase of the latest studies on widely known coccidia, including Eimeria and Toxoplasma in addition to the emerging or re-emerging parasites such as Neospora, Cryptosporidium and Cyclospora. This meeting was staged in conjunction with the Annual Scientific Meeting of the Australian Society for Parasitology.

Brunner's gland adenoma with circumferential duodenal involvement.

Brunner's gland adenoma is a benign tumor of the duodenum. We report a 58-year-old man who presented with abdominal pain, vomiting and weight loss. The patient underwent Whipple resection along with lymph node clearance. The resected tumor, 4 cm long, showed hypertrophied Brunner's glands.

Invasion of different cell types by sporozoites of Eimeria species and effects of monoclonal antibody 1209-C2 on invasion of cells by sporozoites of several apicomplexan parasites.

Sporozoites of avian Eimeria species differed markedly in their ability to invade cells in vitro. Invasion by E. tenella and E. adenoeides was significantly greater in baby hamster kidney (BHK) and chicken cecal cell (CC) cultures than in primary chicken (PCK) or turkey kidney (PTK) cell cultures. Moreover, invasion of BHK cell cultures by E. adenoeides was significantly greater than that of other Eimeria species, and invasion by E. acervulina sporozoites was significantly lower. Monoclonal antibody 1209-C2 (MAb 1209-C2) reacted by immunofluorescent labeling (IFA) with refractile bodies of sporozoites of 5 species of Eimeria and Caryospora bigenetica, but not with sporozoites of Toxoplasma gondii, Hammondia hammondi, or Cryptosporidium parvum, which have no refractile bodies. The MAb also cross-reacted with formalin-fixed BHK, CC, turkey cecal (TC) cells, and PTK. Pretreatment of BHK cells with MAb 1209-C2 significantly reduced invasion of the cells by sporozoites of E. tenella, E. acervulina, E. meleagrimitis, and C. bigenetica, but did not alter invasion by T. gondii, C. parvum, or H. hammondia. Apparently, reactivity of MAB 1209-C2 with the sporozoites was required for inhibition of invasion despite the fact that the inhibition resulted from pre-treatment of the host cell. Conversely, although MAb 1209-C2 also reacted moderately with PTK and TC cells, pre-treatment of these cell cultures with the MAb did not inhibit invasion by either MAB 1209-C2-reactive or -nonreactive parasites. Collectively, the data indicated that refractile body antigens of sporozoites of Eimeria and Caryospora, which are recognized by MAb 1209-C2, may function in cellular invasion, but also suggest that cellular invasion is probably not mediated by interactions between the conserved epitopes in sporozoites and cultured host cells that are recognized by the MAb.

Dielectric properties of certain biological materials at microwave frequencies.

In the medical field, microwaves play a larger role for treatment than diagnosis. For the detection of diseases by microwave methods, it is essential to know the dielectric properties of biological materials. For the present study, a cavity perturbation technique was employed to determine the dielectric properties of these materials. Rectangular cavity resonators were used to measure the complex permittivity of human bile, bile stones, gastric juice and saliva. The measurements were carried out in the S and J bands. It is observed that normal and infected bile have different dielectric constant and loss tangent. Dielectric constant of infected bile and gastric juice varies from patient to patient. Detection and extraction of bile stone with possible method of treatment is also discussed.

Use of monoclonal antibodies developed against chicken coccidia (Eimeria) to study invasion and development of Eimeria reichenowi in Florida sandhill cranes (Grus canadensis).

Eimeria gruis and Eimeria reichenowi are common coccidial parasites of a number of species of cranes. Until recently, little was known about either the site for invasion or the dynamics of early development of the crane coccidia because of the difficulty of identifying sporozoites and early developmental stages of these parasites by conventional staining methods. In the present study, monoclonal antibodies (MAbs) elicited against Eimeria spp. of chickens and turkeys were found to cross-react with sporozoites and developmental stages of E. reichenowi in the tissues of Florida sandhill cranes (Grus canadensis). With these Mabs, E. reichenowi sporozoites were found in specimens taken at 6 hr postinoculation (PI) from just proximal to Meckel's diverticulum in the jejunum to the ileocecal juncture. Fewer were found in the ceca and rectum and none in the duodenal loop. At 24 hr PI, there were markedly fewer sporozoites and their location had shifted to the duodenum. No stages were seen in intestinal cells at 5 days PI (DPI), but trophozoites had developed in the liver and spleen. At 10 DPI, sexual stages were detected in the intestine from the duodenal loop through Meckel's diverticulum but not in other organs. By 14 DPI, numerous developmental stages were detected in the intestine (ceca and jejunum), liver, and lungs but not in the heart, kidney, or brain. The number, location, and maturity of the stages in the ceca differed markedly from those in the jejunum.

Treatment of peptic ulcer disease in the Helicobacter pylori era.

All patients with gastroduodenal ulcer disease should be tested and treated for Helicobacter pylori whether the ulcer is active or in remission. The rapid urease test, being the most commonly available, is the test of choice in our country. It is prudent to do H. pylori serology in the case of bleeding ulcers. Physicians should choose the regimen with the greatest efficacy regardless of costs. Bazzoli's low-dose triple therapy seems to be an excellent choice from our experience. Outside study protocols, routine checking for ulcer healing and eradication of H. pylori is recommended only for complicated ulcers. However, symptomatic patients need to be re-investigated with endoscopy and rapid urease test.

Effect of polyclonal antisera developed against dense granule-associated Neospora caninum proteins on cell invasion and development in vitro by N. caninum tachyzoites.

The effects of polyclonal antisera to 2 recombinant dense granule (DG) antigens of Neospora caninum on invasion and development by N. caninum tachyzoites in baby hamster kidney cell cultures were examined. In immunofluorescent antibody tests, the anti-DG sera, at dilutions of 1:100 to 1:500, reacted intensely with individual intracellular tachyzoites and groups of tachyzoites enclosed in parasitophorous vacuoles at 2 and 52 h p.i., respectively. Tachyzoites suspended in diluted anti-DG sera and inoculated immediately into the cell cultures invaded cells in significantly fewer numbers (53-68% fewer by 2 h p.i.) than tachyzoites suspended in similarly diluted normal rabbit serum. In contrast, tachyzoites suspended in anti-Eimeria tenella sporozoite serum invaded cells as efficiently as those suspended in normal rabbit serum. Addition of anti-DG sera at the time of inoculation of tachyzoites, or to the cell cultures after the parasites had entered cells, had little effect on either the percentage or rate of their subsequent development.