Lymphatic filariasis has been identified as one of the six diseases that can be potentially eliminated. Global programme to eliminate lymphatic filariasis has been launched, applying principal strategies of mass drug administration to interrupt transmission and morbidity management to prevent disability. The strategy for mass drug administration has been clearly laid out and guidelines have been well documented for implementation, monitoring and evaluation of the programme but such a guideline is warranted for morbidity management and disability prevention activities.Health Related Quality of Life, a multidimensional construct referring to patients' perceptions of the impact of disease and treatment on their physical, psychological and social function and well being is crucial in the evaluation of health care interventions. Lymphatic filariasis has a wide clinical spectrum and disability is more pronounced in the advanced stages of lymphoedema and hydrocele. Since the advanced stages of lymphoedema are not reversible, morbidity management and disability prevention activities can lessen the disabilities due to secondary infections and there by improve the quality of life of the patient. Thus, an improvement in quality of life is considered to be important as a primary outcome in the determination of therapeutic benefit. Therefore it can be used as an indicator to assess the impact of morbidity management and disability prevention activities in global programme to eliminate lymphatic filariasis.Disease specific Health Related Quality of Life instrument can be used to measure the longitudinal changes in quality of life of patients following the intervention. High responsiveness, clinical relevance to patients and its sensitiveness to detect small changes are the merits of disease specific instrument. Morbidity management and disability prevention activities under filariasis elimination programme aim at improving the quality of life of patients with irreversible manifestations. Therefore there is an urgent need to develop an instrument to assess the health related quality of life, specific for lymphatic filariasis by incorporating all the difficulties and problems caused to patients by the disease in the physical, mental and social domains of health. Lymphatic Filariasis is an important public health problem in many tropical and sub-tropical countries. Globally, 1.3 billion people are at risk of infection and about 120 million people are affected in 83 countries . GPELF hInternational Classification of Functioning, Disability and Health (ICF) and WHO Disability Assessment Schedule (WHODAS) [Although GPELF programme has gathered momentum, there are some issues to be resolved for achieving the desired results of the programme. One among them is the low priority given to morbidity management programme. The reason for this may be the limited availability of resources including trained personnel and surgical facilities for performing hydrocelectomies. The strategy for MDA has been clearly laid out and guidelines are available for monitoring and evaluating the MDA programme and are being followed by the implementing countries. The epidemiological indicators such as microfilaria (mf) prevalence and mf density levels are used to assess the impact of MDA programme . Ultimat(WHODAS)  for asseThere is an increasing recognition that what matters most to patients is how well they are able to function in their day-to-day life  and the The concept of HRQoL is used as an important parameter for measuring outcome in modern medicine. This can be used as discriminative as well as an evaluative indicator. Therefore HRQoL can be considered as an indicator to assess the impact of MMDPA in GPELF. HRQoL can be measured using both generic and disease specific instruments . GenericGuidelines for ELF programme implementation and monitoring are necessary for the programme managers at different levels. Such guidelines are already available for MDA, but warrant one for MMDPA. Monitoring the impact of intervention is an inbuilt component of the programme and is essential to assess the progress and endpoints. Though WHODAS has been recommended as a generic instrument, it can not be considered as more appropriate. HRQoL can be used as an indicator to assess the impact of MMDPA and LF specific HRQoL instrument (LF-QoL) is appropriate, as it can be developed to assess the health outcome in terms of quality of life. MMDPA aims at reducing the morbidity and improving the quality of life of chronic patients, which is irreversible. This is not only useful to assess the effect of home management to prevent secondary infection and progression of disease, but also to assess the impact of surgical corrections of hydrocele patients. LF-QoL can be developed following standard methods described elsewhere ,16. All The author(s) declare that they have no competing interests.AK drafted the original manuscript and currently working on the development of LF specific instrument to assess the quality of life; KK conceived the idea in developing potential alternative measure to assess the impact of morbidity management interventions against LF and reviewed the document; KTH assisted in organizing bibliographic data base and LKD contributed in developing the concept and reviewing the manuscript.


The issue of organ donation and of how the donor pool can or should be increased is one with significant practical, ethical and logistic implications. Here we comment on an article advocating a paradigm change in the so-called "dead donor rule". Such change would involve the societal and legal abandonment of the above rule and the introduction of mandated choice. In this commentary, we review some of the problems associated with the proposed changes as well as the problems associated with the current model. We emphasize the continuing problems with the definition of death and the physiological process of dying; we discuss the difficulties associated with a dichotomous view of death; we review the difficulties with non-beating heart donation and emphasize the current limitations of society's understanding of these complex issues. We conclude that public education remains the best approach and that such education should not be merely promotion of a particular ideology but honest debate of what is socially and morally acceptable and appropriate given the changes in vital organ support technology and the need to respect patient autonomy. In the last 40 years, transplantation has become an effective therapy for end-stage organ failure. The vast majority of viable organs are retrieved from patients who, according to the dead donor rule, are considered to be dead because of irreversible cessation of either cardiac and respiratory function or all brain function . UnfortuAs for DCD, Verheijde and colleagues now propose a "paradigm change to ensure the legitimacy of DCD practice", which should include societal and legal abandonment of the dead donor rule and mandated choice in order to promote individual participation and to specify personal decision about organ donation . This apprimum non nocere) and respect for persons. We propose that individuals who desire to donate their organs and who are either neurologically devastated or imminently dying should be allowed to donate their organs, without first being declared dead. Advantages of this approach are that (unlike the dead-donor rule) it focuses on the most salient ethical issues at stake, and (unlike the concept of brain death) it avoids conceptual confusion and inconsistencies"  is based not on brain death and the dead-donor rule, but on the ethical principles of non-maleficence  shows very clearly how much opposition this approach would meet.An alternative approach is to abandon the above-mentioned dichotomy and recognise the necessity to make prudent decisions in situations where the border between life and death is presently unknown. Modern technology has already intruded into the process of dying and has changed it dramatically. The traditional concepts of life and death are totally inadequate to describe the new situations created by intensive care medicine.appears to be a point of no return in the process of dying. Yet, as we already wrote  today have focused their efforts on convincing members of the public to become organ donors rather than on providing adequate unbiased information and education about organ donation".We should not confuse genuine education and improving awareness and attention to public health issues with manipulation of people's ideas and opinions. We need to educate people to what is happening now. Anyone who has had to speak (as we regularly do) to families who have just lost a 20 year-old son and then had to get them to grasp the idea of organ donation and the concepts that surround it, knows that the community is a million miles away from the concept of "changing the rules".The author(s) declare that they have no competing interests.Dr. Zamperetti wrote the first draft, Dr. Bellomo revised it thoroughly. The final manuscript was the result of multiple mutually agreed modifications by both authors.


Sir,Regarding the research methodology paper entitled "Sample size calculation" by Kadam and Bhalerao, which waI would also like to point out that in some cases one can screen and study the whole target population contrary to what is said at the beginning of the fi rst paragraph. "It is naturally neither practical and feasible to study the whole population in any study." For example, the study which assessed the possible association of bronchial asthma with the inhalation of volatile acids in dark rooms amongst the radiographers evaluated the whole population then being a total of 100 radiographers in the Gaza Strip in Palestine and all


Changes in clinical practice are brought about by the weight of clinical evidence for and against an intervention. Clinical evidence of efficacy relies on the dissemination of research results, usually by publication in medical journals which is often seen as a pre-requisite for progression of an intervention through further clinical trials or implementation studies.We undertook an exploratory exercise to determine where basic and translational medical research is currently published. Original research articles  published in high impact general and specialist medical journals were classified into different stages of research within the translational medicine pathway.The general medical journals had the broadest spread of published research over the translational pathway. The specialist journals tended to be positioned to disseminate the research findings of early stage translational research from basic science results through to early stages of clinical testing.It is not possible for one journal to satisfy all the needs of the reader and the author along the translational medicine pathway. For an intervention to progress along the translational pathway background information should be readily accessible in the article. This pathway is currently being actively managed by the funding agencies but the next challenge is to ensure the pathway operates efficiently and does not allow promising innovations to languish and to provide a smoother transition for interventions to reach the clinic in a quicker timescale. It is clear that the dissemination of results in the right place at the right time is crucial to the transition of an intervention from the laboratory to clinical practice. The status of translational research  has drawn increasing attention as it is seen to be essential to the development of new treatments from advances in biomedical science -5. In 20Within the UK, the Cooksey report resulted in the reorganisation of research funding and the creation of several new funding programmes, with the aim of producing a managed translational pathway Figure  which woThe aim of the translational pathway is to ensure that clinical studies for new treatments or diagnostics at all stages of development or evaluation have the potential to gain funding. For the purpose of this article the translational pathway has been divided into four categories of research; early, efficacy, effectiveness and other. The early research category covers research and development for basic discoveries and for new therapeutic/diagnostic/device/public health intervention (or a new indication for an existing intervention) from basic science through to early phase clinical studies with the aim of establishing proof of concept in humans. The efficacy category includes all research which aims to establish definitive proof of efficacy for an intervention , to the point where, in the example of a drug, marketing authorisation could be sought or widespread use in healthcare supported. The effectiveness category includes all research which aims to investigate effectiveness, costs, and the broader impact of health technologies for those who use, manage and provide care in the health service. The other research category encompasses all research which is not covered by the previous three categories; research that falls into this category generally sits further along the translational pathway and includes service delivery, health service, global health and public health research as well as epidemiology and modelling. The challenge is to ensure that the benefits of translational research are delivered as changes in clinical practice.Changes in clinical practice are brought about by the weight of clinical evidence for and against an intervention. This involves assessment of the quality of the evidence, the risks and benefits of treatments, and the impact of implementation on clinical care pathways by practitioners and those determining healthcare policy. Clinical evidence of efficacy relies on the dissemination of research results, usually by publication in medical journals which in academic models is often seen as a pre-requisite for progression of an intervention through further clinical trials or implementation studies. Therefore, publication of translational research is a critical step - how and where, results are published will often have an impact on further progression through the pathway and can inform research managers where to target their resources. A recent review identified 101 articles between 1979-1983 in 6 top basic science journals that had apparent promise for development as a major clinical application. But over twenty years later, only five of these promising advances were in licensed clinical use and only one of them had had a major impact on current medical practice. Three quarters of the promised interventions resulting from these basic science papers had not yet been tested in a randomised trial. The article reported that the strongest predictor of moving to randomised experimentation was industry involvement in the original basic science publication [Publication is seen as a major output for research, though clinical impact is its goal, as well as having financial implications for the research groups involved through research assessment exercises that often use publications as a surrogate. It is certainly true that the readership of a journal varies, and it is possible that in some cases, publication in specialty rather than general journals may be more appropriate and influential in the progression of an intervention. To investigate if this is possible we undertook an exploratory exercise to determine where basic and translational medical research is currently published.Two authors (LD and IC) independently classified original research articles  published in the high impact general medicine journals Nature Medicine, New England Journal of medicine (NEJM) and The Lancet from July-December 2008 and one month (October 2008 was chosen as it was in the middle of the time frame studied) of seven high impact speciality journals; American Journal Respiratory Critical Care Medicine (AJRCCM), Circulation, Gut, Journal Clinical Oncology, Journal of Orthopaedic Research, Lancet Neurology and finally Ophthalmology. The articles were classified into one of four phases discussed in the introduction; early research, efficacy research, effectiveness research, and other research. In some of the papers reviewed the information needed by the reader to determine where the research sat along the translational pathway was not always readily available within the article. Articles over which there was disagreement over the classification  were independently classified by a further two authors (VT and DP). Any remaining disagreements over articles were resolved by discussion between all four authors.From our exploratory study it has been possible to detect some early trends in the research published by the selected journals. The general medical journals, The Lancet and NEJM had the broadest spread of published research over the translational pathway. In the time frame investigated the NEJM published more efficacy research (40% of articles) than early research or effectiveness research, which combined constituted only 30% of the articles. Whereas, all stages of translational medicine were more equally represented in The Lancet. In the period studied both efficacy and effectiveness research was well represented in this journal, with each of these categories contributing 20% to the total number articles published. The 'other research' category was well represented by these two journals and although not clearly demonstrated by figure From the limited selection of specialist journals analysed it appeared to be clear that they are positioned to disseminate the research findings of early stage translational research from the basic science results through to the early stages of clinical testing; all journals, with the exception of ophthalmology, consist of at least 50% early and efficacy research. Effectiveness research is much less prevalent in the selected specialist journals with only Circulation and Lancet Neurology publishing a noteworthy number of these trials at 17% and 25% respectively figure .Again the other research section is not further analysed here, but Gut, Circulation, Ophthalmology and Journal of Clinical Oncology publish a substantial amount of research in the public health and service delivery aspects of medicine figure . EpidemiThe specialist journals are also limited by how far the interventions for their speciality are along the translational pathway, for example orthopaedic research involves a lot of basic research which is only just starting to be translated into clinical studies. If this analytical approach to studying publications were expanded it seems likely that it could be exploited by research commissioners to ensure promising treatments are actively translated into clinical practice.It is obviously not possible for one journal to satisfy all the needs of the reader and the author along the translational medicine pathway. Even in this small sample of journals the positioning of the journal in the translational pathway is likely to affect the chance of an article falling within the first gap in translation being published in the journal of choice. The general medical journals The Lancet and the NEJM publish a wide range of research that reflects the wide ranging readership of the general medical journals, though the recent study in Science  suggestsSome of the articles were difficult to categorise, even with four independent opinions, as the background information on the research was not always available, without searching the references. This has important implications for the development of the clinical evidence base as some of the research may be overlooked as it is not clear where the intervention is along the translational pathway. It is debatable whether any intervention pursues a linear progression along this artificial pathway: as often multiple advances, both scientific and technical, lead to a change in clinical practice.However, in our view, it is essential that the managed translational pathway should prevent the potential loss of valuable information by actively managing it through the different stages involved. This pathway is currently being actively managed by the funding agencies. The focus is now to ensure that the pathway operates efficiently and does not allow promising innovations to languish without a funder, providing a smoother transition for interventions to reach the clinic in a quicker timescale. The challenge is to ensure that the benefits of translational research are delivered as changes in clinical practice. From this exploratory study, it appears that the dissemination of results in the right place at the right time can be critical to the transition of an intervention from the laboratory to clinical practice and the medical journals have an important role in supporting this process. Further work will needed to draw firm conclusions, but we hope that these results will provoke thought and discussion as to how publication could better influence translation of research into clinical practice.1. Where an article is published mirrors the progression of an intervention along the translational medicine pathway.2. The journals chosen appeared to publish work which is at particular stages along the translational pathway.3. To evaluate the progress of an intervention along the translational pathway it is helpful if previous work is described to clearly demonstrate where the intervention is within the pathway.4. The medical journals have a key role alongside the funders of the managed translational pathway to ensure interventions move from basic science to clinical practice quickly and smoothly.All authors declare that the answer to the questions on your competing interest form are all No and therefore have nothing to declare.This research was carried out by the NIHR Evaluations Trials and Studies Coordinating Centre. No additional funding was sought for this research.Ethical approval was not required for this research.LD and IC were involved in all stages of this study; DP and VT assisted with classification of articles. All authors critically reviewed and agreed the final draft. LD and IC are the guarantors.


The ascorbyl radical concentration has been observed, by means of electron spin resonance spectroscopy, in the blood, spleen and liver of RF/J female mice throughout the development of a myeloid leukaemia. Changes in the concentration of the radical were detectable from an early stage in the disease and did not appear to be directly due to the leukaemic cells but could possibly be due to a reaction against them. Changes in the concentration of the paramagnetic metal ions during the leukaemia have been reported previously and it was found that changes in some of these species correlated with changes in the ascorbyl radical concentration.


With the rapid strides in the perfection of surgical techniques and with the advances in the pre and postoperative care of the patient, it is almost imperative to obtain an early and accurate pre-operative diagnosis of emergencies in the new born infant. It is a well documented fact that next to birth traumas, the commonest cause of death in the newborn is the complication of developmental anomalies. Roentgenological examination is of enormous importance in the early diagnosis of these emergencies of the alimentary tract as reliable objective evidence can be obtained at the time when the diagnosis is a matter of conjecture on the basis of clinical evidence alone. In the newborn there occur not infrequently, congenital anomalies, that if left untreated, result in death. Prompt recognition and adequate surgical correction of the anomaly will result in a gratifying low morality rate. Not only is the mortality in a given case directly related to the promptness of diagnosis and proper surgical treatment but also to the period of recovery and convalescence in the hospital which is uneventful and minimised to a considerable extent. It has been a common opinion among the medical profession that the newborn infant cannot withstand surgical procedures and that operations should be delayed on this ground whenever possible. But Ladd has poinWith the first breath of life air enters the pharynx, esophagus and then passes on into the stomach and intestines. As the baby goes on swallowing air, large amounts are visible in the small and large bowels within 12 hours after birth, depending upon the active crying of the baby. About 80% of the gas that is seen in the alimentary tract is due to swallowed atmospheric air. Experience tells us that, whenever the baby does not cry actively due to some reason or other, the amount of gas seen in the alimentary tract is slight in the first 12 hours. This presence of gas and its distribution in the small and large bowels serves as a contrast medium and helps in identifying the various anatomical segments of the alimentary tract and locate the site of obstruction when present.One of the gravest congenital anomalies is esophageal atresia with or without tracheoesophageal fistula. This anomaly is more common than is usually considered to be the case. There are several morphological types, the commonest being the one with atresia of the proximal end forming a blind pouch, the distal segment being in communication with the trachea or one of the main bronchi. According to Caffey more thaThe roentgenoligical diagnosis is confirmed by passing a soft rubber catheter into the esophagus and finding an obstruction at about the level of the second or third dorsal vertebrae. This procedure as well as the injection of one or two c.c. of lipiodol through the catheter to outline the upper esophageal segment and its blind pouch should be performed under fluoroscopic control. Such an examination with the help of a spot film demonstrates the level of the upper esophageal pouch as seen in This is a congenital anomaly of indeterminate origin and as a rule the upper descending portion of the duodenum is involved but any portion may be encircled. The circle may not be complete always. It is a rather rare extrinsic cause of congenital duodenal obstruction. Slight degrees of obstruction go undetected throughout life. One of Poppel's cases waAcute intestinal obstruction in the new born, is sometimes produced by atresia or stenosis of a segment of the small bowel. This is the commonest cause of intrinsic intestinal obstruction resulting from failure of complete re-canalization of the epithelial tube in embryonic life. Atresia results from an imperforated intestinal diaphragm or a solid occluding epithelial plug, whereas stenosis results when small channels exist through these diaphragms or plugs. Attention is directed to these patients because of persisting vomiting of bile-stained material, which starts soon after birth. The site of obstruction usually determines the abdominal distention.Roentgenological examination should be limited to scout films of the abdomen in various views wherever it is possible. From the scout films alone, the point of obstruction could be located as no gas is found beyond the stenotic segment. In case of complete intestinal obstruction, barium should never be administered by mouth. As has been mentioned before, the child might aspirate the barium into the lungs during the act of vomiting or the barium might form a concretion in the bowel, which becomes a hazard to the patient post-operatively after an anastomosis circumventing the atresia has been made. When the atresia or stenosis is in the terminal loops of the ileum and when there is enormous gaseous distension proximally, at times it is difficult to distinguish it from a large bowel distension. As a rule, in all doubtful cases to make out whether it is small or large bowel obstruction, it is always safer to do a barium enema. This helps in ruling out a large bowel obstruction This pathological entity owes its recognition mainly to Farber and NeuhThe roentgenological findings are basically similar to any type of small bowel obstruction. In cases of complete obstruction, the scout films reveal pronounced distension of the small bowel with air-fluid levels demonstrable in the erect or lateral recumbent postures. However, in some cases, a small amount of gas is forced into the tenacious and mucilaginous meconium and is seen as small bubbles of gas scattered in the small bowel. Neuhauser has poinThe rarer complication of volvulus of the segment of bowel occluded with meconium should be borne in mind when it becomes a real surgical emergency. This disorder is a nonbacterial chemical peritonitis, which results from the extrusion of meconium through the intestinal wall into the peritoneal cavity. Whether this process goes on in late fetal life or immediately after birth is not definitely know. Variable amounts of lime are usually deposited in the extruded meconium in the form of incrustations on the clusters of cornified epithelial cells. When the calcified masses are large enough they can be visualised on the scout films of the abdomen. These calcifications are usually circular or curvilinear, irregularly distributed in the abdomen. These calcifications associated with small intestinal obstruction, are fairly characteristic of meconium peritonitis. Imperforate anus is one of the most frequent emergencies in the newborn and is promptly recognised without an X-Ray examination. The complexity is not appreciated however, since this anomaly is commonly associated with atresia of the rectum and some type of a fistula; rectovaginal, rectoperineal, rectourethral or rectovesical. In some cases, the rectum and the rest of the colon are normal except for a cutaneous septum in the region of the anus. An infant with this type of imperforate anus will rapidly develop marked gaseous distension of the intestines within a few hours of birth. It is of prime importance to determine how low the rectal pouch is in the pelvis to help in determining the type of operation that is going to be employed.Using Wangensteen's technique of inverting the baby and placing a metallic marker on the perineal dimple, it is possible to determine how near the pouch is to the perineum by taking a lateral view of the pelvis . This mePartial or complete absence of a hemidiaphragm is not so common as is thought to be. Unless it is recognized early and treated radically, the morality rate approaches 80-90%. Of all varieties of anomalies of the diaphragm, the commonest is the defect in the pleuroperitoneal membrane region, especially on the left side. This results in massive herniation of the abdominal contents into the thoracic cavity. The newborn presents with characteristics attacks of cyanosis associated with dyspnea particularly during or shortly after feedings. Roentgenological examination of the chest and abdomen presents the true picture of the herniation. The chest reveals the heart and mediastinum to be pushed to the opposite side of the hernia. The presence of gas distended gastro-intestinal tract in the thoracic cavity cannot be mistaken for any other condition. One may administer lipidiol by mouth for identification and location of various portions of the gastrointestinal tract, and thus confirm the diagnosis as well This anomaly of developmental origin is such a striking abnormality in the newborn that it usually receives prompt attention by the clinician. This condition consists of herniation of the abdominal contents into an abnormal sac-like umbilical cord, which consists of a translucent membrane composed of peritoneum and amniotic membrane. In rare cases, the infant may be born with an omphalocele in which the sac is absent. Roentgenological examination is imperative whenever there is clinical evidence of intestinal obstruction or strangulation. Anteroposterior and lateral views of the abdomen reveal the typical obstruction pattern of the bowel as previously described. In addition, the gas distended loops of bowel can be traced lying outside the anterior abdominal wall. However, occasionally associated abnormalities such as sacrococcygeal dermoid can also be detected as in one of our cases which is shown in Malrotations of the gastrointestinal tract and faulty mesenteric attachment may rarely lead to volvulus of the mid or hind-gut. In these cases, scout films of the abdomen suggest a picture of intestinal obstruction but do not help usually in making an etiological diagnosis. In cases of non-rotation of the hind-gut, a barium enema of the colon reveals the abnormal position of the cecum, which will be situated on the left side of the abdomen.The much rarer anomalies such as pericardiodiaphragmatic herniation and reduplications of the alimentary tract with complications of obstruction and strangulation of the intestines deserve mention and roentgenological examination with contrast media plays a very important role in the postulation of a diagnosis preoperatively.An attempt has been made to stress the importance of roentgenological examination in establishing definite preobservation diagnosis in some of the alimentary tract emergencies in the newborn. A brief account of the roentgenological criteria has been given with illustrations of surgically proved cases whereever possible. A short list of pertinent references is appended.


More and more complicated laparoscopic abdominal surgeries are now being performed across the world. Laparoscopic suturing of the bowel perforations is being performed by experienced surgeons. We have developed our own technique of small bowel anchoring to the abdominal wall before suturing the perforation.A single stitch is taken at the corner of the perforation. The long end of the suture is retrieved by a suture retrieval needle and the small bowel is anchored to the abdominal wall. Rest of the bowel perforation is suture by the intracorporeal knot-tying technique.Anchoring the bowel to the abdominal wall helps in fixation of the bowel to be sutured. This helps specifically for large perforation. Suturing and knot tying is relatively easy by this technique. The advent of laparoscopic surgery has added a new dimension to intraabdominal surgical procedures. Almost all complicated intraabdominal surgeries can be performed by laparoscopy.2 Many re3For the closure of large perforations of the small bowel, we adopt our technique of anchoring the small bowel with the abdominal wall. We take the single stitch at the corner of the perforation and tie the suture . One endThe conventional method for laparoscopic closure of small bowel perforation is to take a simple stitch through the bowel wall. There may not be any difficulty during this maneuver if the perforation is small and two or three stitches are to be taken. The problem arises when the perforation is very large, like traumatic jejunal perforation or closure of the enterostomy after wedge resection of the Meckel's diverticulum. Because the small bowel is not a fix structure, closure of such a large perforation is difficult. By adopting our new method for anchoring the small bowel, we have observed that the suturing is easier. The small bowel is hanging in front of the camera and the perforation to be suture is just in front of the working instruments. As the bowel is hanging, it is much easier to take suture and tying a knot than the bowel that is lying free on the floor of the abdomen.


Allograft rejection is a complex process, which requiresinteractions between different cell types and a variety of solublefactors, such as cytokines. In this review we discuss the role ofcytokines in the induction and effector phases of the rejectionprocess and in the induction and maintenance of allospecific grafttolerance. Furthermore, we discuss the feasibility of clinical graftfunction monitoring by measuring cytokines and the possibilities forintervention in the cytokine network in order to inhibit graftrejection and eventually obtain graft acceptance.


The Emergency Departments (EDs) provide medical care to a population with increased needs for preventive care and limited access to screening and preventive interventions linked to stress. EDs are well positioned to provide data on several aspects of public health and give an opportunity to initiate preventive services for many people, to identify preventive interventions and, secondarily, to recommend areas in which research into the efficacy and cost-effectiveness of interventions are needed. The adoption of these initiatives may improve the health of this vulnerable population.Patients are not always satisfied with the care received at EDs. More attention needs to be paid to the specific needs and expectations of the nonurgent group of patients who make up the majority of attenders at many EDs. Identifying areas for quality improvements are important to know where to take action. These findings may facilitate the work with changing attitudes and working routines, which are needed to deliver effective care and to improve the patients' perceptions of quality of care at EDs.In 2000, the Society for Academic Emergency Medicine Public Health and Education Task Force developed recommendations for prevention, screening and counseling activities to be conducted in EDs. In the EThere is a lack of information about the prevalence of stress, types of stressful situations and the relationship with other health issues in the ED population. This lack of knowledge of current evidence causes effective preventive and screening interventions from having not been widely adopted in the EDs.For example, the unexplained chest pain is a common reason for emergency hospital admission and generates considerable health care costs for society. These patients report perceived stress at work and more prevalence of overweight. In patieThe stress induces endocrine and immune changes as elevated levels of serum corticosterone and nerve growth factor and the chronic stressors suppress immune function and increase a host's susceptibility to disease. Also, the seasonal changes influence the immune function and the increased blood concentrations of adrenocortical steroids in response to them compromise immune function and accelerate catabolic mechanisms. Thus, there are mechanisms in some animals to combat seasonal stress-induced immunocompromise as a temporal adaptation to promote survival. In relation with this, the incidence and mortality of sepsis and severe sepsis are seasonal and consistently highest during the winter, predominantly related to respiratory sepsis.Further research should be directed not only to more efficient ways of identifying organic causes of disease but also to a more systematic evaluation of their symptoms, or the potential effects of lifestyle counseling in this large ED-patient population.et al.[In this manner, Nirenberg et al. studied Brief interventions delivered to ED patients can be efficacious in reducing some unhealthy behaviors. There are articles that provide an overview of health promotion and disease and injury prevention concepts, discussing examples of innovative emergency medicine-based preventive activities, including prevention in the prehospital setting.It is necessary to integrate proven preventive and other public health initiative interventions into the ED setting in the emergency medicine core curriculum to configure clinical information systems to facilitate public health interventions and to use ancillary ED personnel to enhance delivery of public health interventions and obtain successful funding for these initiatives.Smoking is the leading cause of preventable death and illness in developed countries and thus the Task Force considers it essential for emergency physicians to provide some recommendations for tobacco control practice. There isThere are authors who recommend the screening and brief intervention for alcohol-related problems in the ED setting because preventing the mortality and morbidity secondary to alcohol-related illnesses/injuries decreases consumption, diminishes the visits of the patients to ED and hospitalizations, decreases the social consequences and increases referrals for follow-up and/or treatment.Besides the stress originated by the physical pain or the incapacity to be able to move or to communicate with the outside, we also have inadequate information that is offered to the patients and the little preoccupation by the professional about the psychological aspects of them. For this reason, it is important to be interested in aspects like the problems or feelings of the patients, reinforcing the information on the procedures to perform, asking for their previous consent and to give them the name of the doctor and the nurse who are treating them. All this would increase the quality perceived by the patient. Also, itIt is not necessary to forget the stress in the personnel who work in EDs, because a relationship exists between working conditions and stress, anxiety, depression and quality of life. The stress at work is connected with the intensity of the burn out and it is a common problem among people who work in an ED. The presence of risk factors derived from work organisation within the work place increases the probability of presenting the burnout syndrome and, above all, the emotional exhaustion. The mostEmergency personnel are continuously under stress because of overcrowded departments, severity of cases and their work schedules. In addition to this work stress, irregular social and family life is the main component of the ongoing burn out process in these professionals. Burn out is the end point of the process, which is complicated by the loss of professional enthusiasm and satisfaction and a negative behavioral approach to the patients. The clin


Greetings to all readers as we move in to the next decade in this millennium. Let us hope to witness several exciting developments in the field of neurosciences that would pave way to the cure of many neurological disorders in this new decade. This year the Annals of Indian Academy of Neurology is entering the 13th year of publication. We hope to bring to you some of these excitements. There had been much progress in the field of epileptology. Dr H V Srinivas, in his Presidential Oration has summarized these developments and has challenged us to meet the future scenario, particularly in the realm of treatment and prevention. There is much research going on to improve the techniques of seizure prediction and stimulation techniques to abort seizures. Some of these methodologies are very promising and are undergoing various stages of clinical trials.Stroke is currently one of the thrust areas of research all across the world. In this issue we carry a review article on optimal secondary prevention of stroke. Patients at higher risk of stroke tend to meet neurologists mostly after the first stroke, although it would be desirable that they are evaluated even before the first stroke. Traditionally, secondary prophylaxis of stroke consists of reducing risk factors for stroke and institution of anti-platelet therapy or antithrombotic therapy. There is much debate about the choice of first antiplatelet, precise dosage of these drugs, and the role of newer antiplatelet drugs. The author has discussed in detail the merits of individual medications and the cumulative evidence base to support its use as an antiplatelet drug. Another issue in this regard is the appropriate use of these medications in special situations such as pregnancy, peripartum period, perioperative period, and in the setting of coronary artery disease or arterial dissection. Dr Mishra and Dr Khadilkar have expressed their view points on what practical steps can be take to improve the of stroke services in this country, especially in view of the vast shortage of neurologists and other experts trained in the management of stroke. In another article on stroke, the authors have addressed the issue of cognitive decline following stroke. In a prospective study, they had observed that more than 30% of stroke survivors had impairment of cognitive functions.−15), whereas that of the earth is 109 times higher (30 to 60 microtesla). The inventions of superconducting quantum interference devices (SQUID) and magnetically shielded rooms have resolved this problem. One of the limitations of SQUID is the obligatory need to have near absolute zero degree Kevin temperature (−291) which is achieved with the liquid helium. Researchers are now attempting to make optical magnetometers that work on the basis magnetic resonance of atomic vapor. The advantage of optical magnetometers is that it can work at room temperature and is likely to be less expensive and less demanding on maintenance. We have included a comprehensive review article in this issue deals with the clinical application of magnetoencephalography in epilepsy. We hope the readers will find these articles and others informative and useful.Magnetoencephalography has left the research laboratories and has found more clinical application in the past decade. One of the technical challenges in this field was in designing appropriate technology to isolate the tiny fluxes in the magnetic fields generated from the brain from the changes in the background. The magnetic field of cerabal activitiy is of the order of a few femto tesla (10This issue onward, we are advancing the actual date of publication of the issues to the beginning of the quarter. This would bring the journal to the readers earlier than before. This would also increase the visibility of the articles. We hope the readers will interact more with the authors through the letter to the editor column.


Plasmodium falciparum in 2002 evoked great hopes for the identification of new targets for novel drugs, these have not yet been fulfilled. This disappointment and the successful use of natural compounds emerging from traditional medicine for the chemotherapy of malaria  have invigorated the search for new antimalarials from natural sources. Hundreds of thousands compounds were screened and some promising leads were identified.Although the completion of genome project of the most virulent malaria parasite However, the great advantage of traditional medicine is a result of demonstrable synergism between the constituents of the crude extracts. The origin and the modes of action of this synergism will be discussed. In conclusion, it is suggested that greater emphasis should be given to traditional medicine and some considerations for its controlled implementation will be mentioned.


The basic requirement for a good calibration is representative data.This paper outlines techniques for selecting samples from an existing population. The concept of factorial designs is explained, and three ways of applying experimental design to generate representative data are described. These are: to vary the experimentalconditions; focus on some of the parameters of interest directly ; to vary the underlying conditions which generate consistent variations in the spectra,for example production factors. Finally the paper gives an example of the use of the conceptof experimental design to pick out samples from a population.


International Seminars of Surgical Oncology without the knowledge or consent of either Prof Karakayali or Prof Haberal, and is being retracted for this reason. An apology is extended to Prof Karakayali and Prof Haberal as well as the editorial and publishing staff and readers of the journal.This article  was subm


The development of drugs in the generic pharmaceutical industry is a highly competitive arena of companies vying for few drug products that are coming off patent. Companies that have been successful in this arena are those that have met or surpassed the critical timeline associated with trial formulation development, analytical method development, and submission batch manufacturing and testing. Barr Laboratories Inc., has been successful in the generic pharmaceutical industry for several reasons, one of which includes automation. The analytical research and development at Barr has employed the use of automated dissolution early in the lifecycle of a potential product. This approach has dramatically reduced the ‘time to market’ on average for a number of products. The key to this approach is the network infrastructure of the formulation and analytical research and development departments. At Barr, the cooperative ability to work and communicate together has driven the departments to streamline and matrix their work efforts and optimize resources and time. The discussion will reference how Barr has been successful with automation and gives a case study of products that have moved with rapid pace through the development cycle


Several situations of great ethical implications are encountered by physicians in daily urological practice. Informed consent for interventions, selection of patients for operative demonstrations and educational workshops, enrollment of patients in clinical trials, and the use of technology are some issues that call for stringent application of ethical principles in decision making. The issues of autonomy, privacy, rights, duties, and privileges that arise have to pass the tests prescribed by contemporary social mores and regulations. Some of the issues encountered, principles applicable, and covenants and documents that guide decision making are discussed. Issues of ethics gain plenty of importance in theoretical discussions in medicine. Several journals have published extensively on ethical debates covering various diverse aspects from teaching medicine to end-of-life issues. In the bustle of everyday clinical practice, some of these issues may not get the attention they merit. It would, therefore, be topical to discuss those that impact our routine clinical work. While a larger debate would certainly be both pertinent and beneficial, only a few common issues are taken up for discussion here.Informed consent is the cornerstone of an evolved social system. Informed consent is routinely obtained from patients, or their legally empowered representatives, for the performance of any intervention that is likely to adversely impact their well-being. However, this is overwhelmingly viewed as a legal document, intended to protect the practitioner from allegations of malpractice and medical malfeasance. The ethics of this informed consent are as important as its legal validity.An individual is vested with the responsibility to care for and control his body. Consequently, he is vested with the freedom to decide on matters that affect its integrity or well-being. Any procOften overlooked are the ethical aspects of informed consent as it applies to children and sometimes the elderly. Obtaining consent from the parents (in the case of children) or the relatives (in the case of the infirm or elderly) is inadequate. Several societies and the International Convention on the Rights of the Child recognisBurgeoning educational initiatives pose ethical challenges that often escape attention. The underlying ethical contract between physician and patient undergoes a change when patients are screened for a workshop by one team, but are operated upon by another team of surgeons. Here, the patients' right to discuss the pros and cons with his care-provider is often subjugated – there is an imposed surrogacy. For example, when a patient is chosen to undergo a complicated surgical procedure by an expert, the process of explaining the surgery, the risks and befits, expected outcomes, possible complications, and the possible corrective measures should complications arise is executed by a surrogate team that by itself may not have the expertise in the procedure performed. This is compounded further by a near-complete absence of meaningful communications between the operating surgeon and the patient undergoing surgery.A feasible solution would lie in the process of consent being undertaken by a suitable local expert who is conversant with the details. Alternatively, the operating surgeon should be available for the patient to discuss matters pertaining to his surgical procedure. Meaningful continuity of care after the workshop is necessary and should be ensured. Several concerns of professional ethics will remain about all this and more –the standard of care, sterility, protocols, and costs.“A physician shall act only in the patient's interest when providing medical care which might have the effect of weakening the physical and mental condition of the patient”. Choosing patients with marginal indications in order to demonstrate an announced or promised procedure is certainly not in the patient's best interests. It is also incumbent on the operating surgeon to ascertain that the procedure will indeed be in the patient's interest as laid down in the International Code of Medical Ethics. To take refuge behind the assertion that the local organisers will have taken care of all necessary documentation will take us back to the dark practices that necessitated the adoption of the Declaration of Helsinki.The dilution of indications for surgery is also a concern. The International Code of Medical Ethics declaresAnother aspect often overlooked is patient confidentiality. Revealing identities and announcing personal details are clear violations of patient's rights. This is very often the first casualty.The advent of drugs for treating various urological conditions and the need to obtain regulatory clearance for these drugs has brought clinical drug trials to the Urologists' doorstep. These trials are undoubtedly to be carried out in accordance with the Good Clinical Practice guidelines of the International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH) – togethThe same rigour applied to surgical decision-making has to be applied here as well. The patient's right to information and autonomy in decision making should be protected. First of all, the physician-urologist has to apply his mind to the study protocol and understand the implications of the proposed treatment or intervention that is to be studied. In the case of drug trials, the data supplied by the sponsors should be carefully perused and independently analysed for consistency and reliability. The physician cannot shirk this responsibility and leave it for the patient to decide and then claim that it was the patient's decision. The offer for inclusion in the study should be made to the patient only if the physician has formed an informed, sound opinion himself that the intervention will benefit the patient. If after this the patient is unable to grasp the nuances of the medication, procedures involved, risks or benefits, it should be taken to mean that the patient has notconsented.Relentless pursuit of patients for recruitment in trials is a practice driven by pressure from the sponsors to show performance. The physician's primary duty is to the patient, not the sponsor! It is here that the physician is at his most vulnerable. Ethics Committees rarely get to evaluate the financial agreements – there is sometimes a higher compensation per patient as the recruitment increases subtly pressurising the physician. Since the professional input that goes into the care of each patient is the same, the higher amount paid is clearly an inducement and no longer compensation, rendering it unethical.The greatest ethical issue with clinical trials is the non availability of the data generated to the investigator – the patient-participant and the physician-participant both do not know the outcome of the trial. What benefit would then avail to the patient? How would the physician know if he acted in the patients' best interest or actually harmed the patient by recruiting them into the trial when proven alternative therapies were available? And then, there is the larger issue of non publication of negative outcomes – results that show that the treatment or intervention was of no use, or even harmful. International non industry agencies are slowly waking up to this.The availability of advanced technology undoubtedly has made surgical treatment outcomes more successful over the years. This has also spawned several questions of ethics as follows:Has the patient been made aware of alternate treatments or technologies – for example, a physician who offers only Percutaneous nephrolithotomy without discussing Shock wave lithotripsy as a solution for the kidney stone.Has the patient been given enough information about the technology to be used and its limitations and risks?Is there enough evidence to support the safety of the new technology and/or its superiority over the earlier ones?Is technological experimentation being thrust on the patient in the name of new technology?Has the financial impact of the technology on the patient been evaluated and explained?Does the patient have access to continuity of care for complications directly attributable to the new technology? Are these reported?Unlike the case of pharmaceutical trials, new technology in urology practice does not require approval from any Ethics Committee or Institutional Review Board. The Indian Council of Medical Research released its Ethical guidelines for Biomedical Research on Human Participants in 2006,Ethics in clinical practice is an issue that has sometimes hovered only in the deep recesses of the physician's professional consciousness. This is no less true in the field of Urology. Issues of autonomy and rights have been codified for a few decades now, yet we find these applied erratically, if at all, in several spheres of urologic practice. The proper communication of benefits and risks should become an integral part of the ethical physician-patient relationship as this alone can help the patient take sound decisions. Calman has idenHopefully, an understanding born out of diligent introspection and reference to established covenants and published documents will result in strengthening the ethical foundations of our current medical practice.


This paper is aimed at studying the usefulness of prostate-specific antigen (PSA) screening for patients with end-stage renal disease (ESRD) and also to assess if the incidence of prostate cancer is higher in this group of patients. The authors screened 1250 men with ESRD aged >50 years for prostate cancer and compared 1007 healthy men aged >55 years in the community who also underwent prostate cancer screening. Prostate-specific antigen > 4 ng/ml was taken as significant and further evaluation including prostate biopsy was done in these cases. The authors found a statistically significant increase in the PSA in the ESRD group than in healthy controls. Thirteen patients in the ESRD group and five in the healthy control men were found to have prostate cancer and were treated as per their staging. The authors conclude that higher levels of PSA are found in ESRD patients and there is higher incidence of prostate cancer in the ESRD group as compared to healthy men.Though the issue of mass screening for prostate cancer in the general population is still a debatable one, reports of higher incidence of prostate cancer in ESRD patients in the lThe study is laudable not only for analyzing such a large number of patients (1250 with ESRD) but also for pursuing the possibility of malignancy in the patients undergoing hemodialysis. With advancement in the supportive care of ESRD more and more patients are living longer and there is no doubt that prevalence of malignant tumors, including prostate cancer is higher in patients with ESRD.Authors have been successful in demonstrating the fact that PSA levels were higher and the incidence of prostate cancer was therefore also higher in these patients with ESRD in comparison to the healthy population. Looking at the treatments offered to these patients, some of the patients did undergo radical prostatectomy and radical radiation therapy for their early stage disease with no significant added morbidity.However, the explanation given by the authors for higher levels of PSA in these groups is not truly satisfactory. They have suggested that lack of urinary symptoms in the presence oliguria, anuria perhaps do not prompt one to look at the possibility of prostatic cancer and therefore more patients present with higher PSA and higher stage. However, we all know that the urinary symptoms directly or indirectly have no bearing on the stage of the disease.


Bacterial symbionts may be used as vehicles for expressing foreign genes in arthropods. Expression of selected genes can render an arthropod incapable of transmitting a second microorganism that is pathogenic for humans and is an alternative approach to the control of arthropod-borne diseases. We discuss the rationale for this alternative approach, its potential applications and limitations, and the regulatory concerns that may arise from its use in interrupting disease transmission in humans and animals.


As the papers in this thematic series have illustrated, the postnatal prevention of mother to child transmission of HIV (PMTCT) strategy has struggled with lack of local relevance. In an attempt to increase our understanding of the great dissonance between the policy intention and the experiences of the participants in concrete PMTCT programmes, we will in these concluding remarks draw upon writings in institutional ethnography. Through the concept of 'global texts' we reflect upon the scientific and ideological underpinnings of the WHO policy guidelines on HIV and infant feeding, and the influence that this policy has had across multiple local settings. The particular impact of the global postnatal PMTCT policy guidelines on the position of breastfeeding lies at the core of the discussion. We close this thematic series titled 'HIV and infant feeding: lessons learnt and ways ahead' by reflecting first, in the present paper, on the lessons learnt during the past decade of PMTCT programme implementation and then, in the subsequent paper, by briefly discussing ways ahead. With an attempt to grasp the meaning and significance of the unexpected and disturbing outcomes of previous PMTCT infant feeding guidelines documented in the papers of this issue we will reflect on them as part of a growing body of policy and implementation documents operating on the global arena. A brief discussion of the production, ideological underpinnings and effects of such documents can, we believe, enhance our understanding of some of the central dynamics at work in efforts to prevent MTCT. The grounded qualitative studies of PMTCT clients and providers presented in this issue reveal the complex and often troubled relationship between such policy guidelines and the 'local', and their particular cultural and political underpinnings and historical provenance.Dorothy Smith has written extensively about the production of what she calls 'global texts' and documents in organisations such as the UN and the World Bank. Her writings reveal how such texts make the co-ordination of thought and action across multiple local settings and times possible . The polSmith argues that 'global documents', in the sense we are talking about here, are constructed through processes of consensus building and produce texts that appear as shared and that create a common ground . The proSmith holds that it is not enough to use global texts as 'sources of information' . Rather This disconnect is not a trivial matter as it obscures the contextual factors that limit the capacity for uptake and adherence by women as the intended beneficiaries of the programme.To facilitate the ambition of global relevance, international policy documents or global texts thus appear as 'existing beyond culture and time'. Such framing of international policy documents has been increasingly criticized. Abu-Lughod  for instThe global PMTCT guidelines of the WHO have a very clear basis in human rights and human development thinking as well as in modern scientific thinking, more concretely in biomedical thinking. Biomedical discourse related to the 2001 WHO infant feeding guidelines  was baseThe implications of a biomedical focus on HIV infection transmitted from mother to child, rather than on infant survival more broadly has been pointed out as a key challenge. This has been powerfully demonstrated in the study from Kwa Zulu Natal published in 2007 by Coovadia and colleagues . The narBeing intrinsically individualistic, rights-based approaches tend to underestimate and obscure the relational bases of women's decision making . As we hAnother problematic feature of the biomedical and rights-based discourses informing the guidelines is that they do not directly address the immense constraints imposed by poverty. The PMTCT guidelines are deployed within - but do not acknowledge explicitly - a global landscape characterized by gross inequity. Although the limitations on choice of infant feeding method implied by resource constraints were recognized by the invention and adoption of the concept of 'AFASS criteria', the concept remains vague and has proven to be very difficult to operationalize and measure. The 2001 infant feeding guidelines  were reaIn line with Abu Lughod  we ask hThe papers in this issue have focussed on the challenges and failures of previous efforts to manage infant feeding practices by HIV positive mothers and postnatal PMTCT counsellors. Taken together, the results of the work have demonstrated how 'global texts' - such as the growing family of PMTCT guidelines - articulate with local exigencies, and are acted upon by individuals and communities at concrete moments in time. Critics of global policy texts argue that their impact or their regulatory strength ultimately depends on their cultural legitimacy and on their embodiment in local culture ,3. The mAt the simplest level the poor applicability of the earlier guidelines to local needs and realities has meant that they have not been able to facilitate the changes in infant feeding practices that they aimed for. In addition, the social and cultural distance between the producers of the guidelines and its many recipients has generated a sense of helplessness, confusion, guilt and fear among the ones involved in the intervention. Women have been unable to adhere to the infant feeding recommendations presented in the guidelines with subsequent emotional stress and fear of harming their infants. PMTCT counsellors have reported uncertainty and loss of faith in their work in infant feeding after experiences with the large numbers of non-adherent mothers. Many are indeed worried that the confusion about infant feeding has reduced the public trust in nursing as a profession .The articles in this issue have revealed the adverse effects produced during attempts at implementing the guidelines, and add important evidence to the growing documentation of a disturbing impact of global policy texts that are out of touch with local lives. Hope lies in the recent shifts in the PMTCT guidelines, shifts that imply a retreat to the promotion of infant feeding practices that are located far closer to customary feeding patterns.The authors declare that they have no competing interests.AB and KMIM wrote the first draft of the paper. PVE was a key person during the workshop and wrote a summing up paper that was drawn upon in these concluding remarks. MMDP and DWS contributed to subsequent drafts. SCL contributed in the writing process. All authors approved the final paper.


Records of 3085 patients registered with breast cancer at the Mersey Regional Cancer Registry have been analysed to evaluate the relative importance of possible prognostic factors. In a subgroup of 1759 patients, clinical stage and histological grade are shown to be strongly related to survival after treatment. In addition histological grade is related to the distribution of times to death after treatment. The results of this and 3 other studies have implications for the design and analysis of clinical trials in the primary treatment of breast cancer.


The well-known peak of bone cancer during the second decade was found to be closely associated with changes in growth velocity at the adolescent growth spurt, for males and females in England and Wales. Distinct accumulations in the second and third decades could be recognized for cancers of ovary, testis, prostate and thyroid. It was suggested that these accumulations and also the bone cancer peak might be a consequence of the growth and development which occur at puberty.


Metals have been used in clinical practice for hundreds of years and for a variety of indications. Although potent agents whose activity may be adapted by manipulation of their chemistry and that of associated ligands, their use has been limited by toxic effects. There is now a burgeoning series of delivery technologies available which may be adapted to the administration of metal based drugs. Together with greater understanding of metal chemistry and their mechanisms of action in disease processes, there is an opportunity to increase the use of metals in medicine by targeting their action more effectively to the therapeutic site and/or protecting the body from toxic effects.


Dear Sir,Hand elevation and immobilization is an essential step following hand surgeries, hand trauma and in oedematous and inflammatory conditions of the hand. This is difficult to maintain in infants and young children (less than four years old) in whom hand elevation is required. The patients in this age group are restless and irritable in the postoperative period and are understandably uncooperative to the elevation and immobilization regimes at other times too. Usage of bandage slings and bolsters/pillows are common ways to immobilize the limb. In addition, the staff nurses and parents/attendants of the patients are advised to maintain a constant vigil in keeping the hand immobilized and elevated. Older children tend to be more cooperative and elevation and immobilization can be maintained by conventional methods.We have devised a simple technique to overcome the aforementioned problems with the utilization of infusion bottles. Following the surgery and/or dressings, we routinely give an above-elbow slab with plaster of Paris, dorsally, maintaining the elbow at 90° flexion and the hand in a supine position. Two infusion bottles are placed on either side of the arm and wrapped with a bandage .The right-angled upper elbow slab has two advantages: first, it doesn't slide down the limb as seen in the lower elbow slabs of the hand and secondly, it helps in maintaining limb elevation. An infusion bottle  is inexpensive and easily available in wards and operating rooms. When they are fastened as bolsters to the arm, they stabilize the limb from falling sideways and the combined weight of the infusion bottles and the slab makes it heavy for the infants and younger children to lift. This ensures immobilization of the limb and prevents them from thrashing the limb around. When the child is to be breastfed or to be taken in the parent's lap or carried around, only the bandage is unfastened and the infusion bottles removed. And when the child is put back on the bed, the bottles and the bandages can be reapplied easily by the parent(s) or the staff nurse.This technique is simple, effective in maintaining position and immobilization and quickly executable at no extra cost to the patients.


Albumin concentrations were reduced in the tumour bearing animals but plasma volumes increased as the tumours developed. Relative increases were seen in the extravascular distribution of albumin, due partly to albumin pooling in and around the tumours and possibly also to general increases in capillary permeability. In the rats there was a considerable increase in the catabolic rate of albumin which was not related to urinary protein loss. The tumour bearing rabbits showed evidence both of increased catabolism and of decreased synthesis and the combination of the two effects resulted in a greater lowering of albumin concentration than was seen in the rats. Possible mechanisms for these findings and their significance in human malignant disease are discussed.Albumin distributions and turnover rates have been studied using


Of 89 samples of cancer cells from ovarian cancer patients primary cultures representative of the cancer cell population could be established in 17. The clinical response to polychemotherapy was studied in relation to the inhibition of thymidine uptake by the cultured cells. Cultures of each patient's tumour were exposed to concentrations of the drugs the patients had been given for long enough to reproduce the area under the curve (AUC) of the plasma levels resulting from in vivo dosage. Full agreement was observed between the degree of thymidine uptake inhibition induced by at least one of the drugs administered to the cultured cells and the degree of clinical response. This approach may prove useful in pharmacological studies as a means of obtaining ovarian cancer cell populations representative of human tumours, even though the number of tumours that can be successfully evaluated in vitro is still too small to serve as a sound basis for prediction.


For each patient sample that is presented to the clinical chemistrylaboratory a combination of various tests can be requested. Thiscombination or profile will depend on the condition of the patient,and hence also on the requesting hospital department. Severaltechniques were applied to detect and describe patterns in testsrequested by the cardiology, hepatology and nephrology sections ofthe out-patient's Department for Internal Medicine. Comparisonof the frequencies of ordering the tests showed significantdifferences between these sections. Cluster analysis and multidimensionalscaling were used to show similarities and differencesin the test profiles that were used by the sections. These techniquesare useful for generating hypotheses, but the statistical significanceof the clustering found is difficult to assess.


A proportionate study was carried out of the causes of death of the 759 Vegetarian Society members whose deaths were recorded in Society records and whose death certificates could be traced. Compared to the general population, a lower proportion of deaths from respiratory diseases and from lung cancer was noted particularly in long-standing members, consistent with the evidence that vegetarians smoke less than the average. The proportion of deaths from colorectal cancer was slightly lower than in the general population but there was no reduction in the proportions of deaths from other diseases that have been linked with meat or fat consumption, such as cardiovascular diseases and breast cancer. The proportions of deaths from stomach cancer and from accidents and violence were greater than expected. The significance of the findings is discussed and also the possible limitations of the proportionate method of analysis in relation to studies of vegetarians.


Laparoscopic approaches to gynecological surgery have been developed by an elite group of highly skilled surgeons. As these procedures become more prevalent in the general gynecological approach to disease and the general gynecologist's approach to treatment, the complication rate for these procedures is likely to increase. In an effort to assist in avoiding these complications, guidelines for the performance of laparoscopic gynecological procedures need to be established. This article presents approaches to the most common gynecological procedures that can assist in the prevention of complications.


A patient is presented with multiple vascular anomalies in the branches of the celiac axis as well as inthe portal vein and its branches. Apparently, unique in the literature is the presence of a large arteriovenousfistula between the hepatic artery and one of the hepatic veins. The anomalies are presumedto be congenital in origin.


Migraine is a common and burdensome neurological condition which affects mainly female patients during their childbearing years. Valproate has been widely used for the prophylaxis of migraine attacks and is also included in the main European Guidelines. Previous (2014) European recommendations on limiting the use of valproate in women of childbearing age did not achieve their objective in terms of limiting the use of valproate in women of childbearing age and raising awareness regarding the hazardous effect of valproate to children exposed in utero. The teratogenic and foetotoxic effects of valproate are well documented, and more recent studies show that there is an even greater neurodevelopmental risk to children exposed to valproate in the womb. The latest 2018 European review from the European Medicines Agency, with the active participation of the European Headache Federation, concluded that not enough has been done to mitigate the risks associated with in utero exposure to valproate. The review called for more extensive restrictions to the conditions for prescribing, better public awareness, and a more effective education campaign in migrainous women. Migraine is one of the most common non-communicable diseases, ranked as the most debilitating disease worldwide in under 50s by the Global Burden of Diseases 2016 , 4. In wTypical migraine crises, which may be up to 3 days long, are characterised by nausea, vomiting, photophobia and phonophobia, and worsen with physical activity. Evolution into the chronic form of migraine is present mainly in female patients and its sequelae may include medication overuse .Treatment of headaches in pregnancy and effects of headache medications on the child during pregnancy and breastfeeding have been reviewed recently . During Valproate has been indicated to treat epilepsy since 1967 and to treat bipolar disorders in Europe since 1995. In some European countries valproate is also indicated in prophylaxis of migraine attacks.Guidelines regarding treatments for acute migraine and preventive therapies have been developed by the Headache and Neurology Societies , 8. ValpValproate is frequently used for the treatment of pre-chronic and chronic migraine, complicated or not by medication overuse. , a scientific committee of the European Medicines Agency (EMA) concluded a review  on the sFirstly, data derived from a meta-analysis   and memory problems –19. InteAvailable data show that children exposed to valproate in utero are at increased risk of autistic spectrum disorder (approximately three-fold) and childhood autism (approximately five-fold) compared with the general population. Limited data suggests that children exposed to valproate in utero may in addition be more likely to develop symptoms of attention deficit/hyperactivity disorder (ADHD) .As a result, based on all the evidence available, in 2014 PRAC recommended restrictions on the use of valproate due to the risk of malformations and neurodevelopmental problems in children exposed to valproate in the womb .Regarding the management of migraine prophylaxis, it was noted that there are only limited data on the efficacy of valproate. The PRAC concluded that valproate should be contraindicated in the prophylaxis of migraine attacks in pregnancy or in women of childbearing age who are not using effective methods of contraception.Changes to the product information including contraindications, warnings and precautions, and updated information on the risks related to exposure during pregnancy to inform the clinicians and women, were agreed. Educational materials for healthcare professionals and patients were recommended.Finally, the pharmaceutical companies for valproate were requested to perform studies to assess the effectiveness of the recommended risk minimisation measures and to further characterise the prescribing patterns for valproate with a pre- and post-implementation analysis and assessment.Fast forward a few years from the 2014 recommendations and new data started coming to light on the effectiveness of the implemented risk minimisation measures from various sources, including a drug utilisation study (DUS) and a healthcare professional survey, both performed by the pharmaceutical companies who market valproate in Europe. It is important to note that the period after implementation of the risk minimisation measures (2015–2016) is rather short and the DUS study is not completed yet. The preliminary data nonetheless suggested that prescribing behaviour changed after implementation of the risk minimisation measures. However there was additional data forthcoming from the joint healthcare professional survey (completed) which indicated that there was room for improvement regarding the knowledge and behaviour of the prescribers.In addition, a number of national initiatives were undertaken in European countries and input from professional and patient representative organisations provided information useful for the evaluation of the effectiveness of the risk minimisation measures.Agence nationale de sécurité du médicament et des produits de santé (ANSM) in France performed a national pharmacoepidemiological study (CNAMTS study - part I) [The  part I)  coveringThe results of the French study provided evidence that, despite the measures recommended following the European review in 2014, exposure of women of childbearing age to valproate had persisted in the country in the reported period including a high level of exposure during pregnancy .Furthermore the results from the French survey conducted between April and June 2016 in a sample of 222 community pharmacies showed that prescribing conditions were not adhered to, especially in the bipolar disorder indication. Conditions regarding supply and use were adhered to in only 36% of the products dispensed among girls and women of childbearing age who had been prescribed valproate by a psychiatrist.Although limited, the results from studies and surveys consistently indicated that the risk minimisation measures of 2014 did not have a satisfactory impact on prescribing patterns.In addition the results also indicated that the switching rates for transfer to other medication in patients at risk were not high enough.Although these observations were identified mainly in the epilepsy and bipolar disorder indications, there are no reasons or data to indicate that these results cannot be extrapolated also to the indication of migraine prophylaxis.Data from all these different sources further confirm the need for improved risk communication among prescribers and patients.In the light of the above the PRAC carried out a further review of the risks and measures to manage them, resulting in new recommendations issued in 2018 .Here only those recommendations relevant to the indication on prophylaxis of migraine are discussed, and specifically the measures that require the involvement of the physician for their implementation in collaboration with the patient. Further details of the full recommendations can be found in the publicly available assessment report of the latest 2018 European review .Updates to the product information were deemed to be necessary in order to reduce valproate exposure during pregnancy. The risks of congenital malformations and neurodevelopmental are, and will always remain inherent to valproate, and cannot be reduced or eliminated. However by reducing or minimizing exposure during pregnancy these risks can be mitigated.The PRAC recommended the contraindication of valproate treatment during pregnancy in the indication of bipolar disorders , 22 and The PRAC also recommended several measures as part of pregnancy prevention programme (PPP) to adhere to.First of all, the individual patient circumstances should be evaluated in each case to guarantee engagement. The treating physician should discuss the therapeutic options with each patient and ensure her understanding of the risks of treatment with valproate and the measures needed to minimise these risks. The patient needs to acknowledge that she has understood the hazards and necessary precautions associated with valproate use and sign a risk acknowledgement form.During the consultation the patient must understand the need to undergo pregnancy testing prior to initiation of treatment and during treatment, as needed.It is essential to ensure that the patient is counselled regarding contraception. Assessment also is needed that the patient is capable of complying with the requirement to use effective contraception without interruption during the entire duration of treatment with valproate. Before contraception is discontinued, the patient must consult her physician as soon as she is planning pregnancy to ensure timely discussion of switching to alternative treatment options prior to conception and so the need for migraine treatment can be re-evaluated. In case of unplanned pregnancy the patient should urgently consult with her physician to organise the discontinuation of the migraine treatment.As the personal circumstances of the patient may change, regular  reviews of treatment need to be performed by a specialist experienced in the management of migraine.These PPP conditions also concern women who are not currently sexually active unless the prescriber considers that there are compelling reasons to indicate that there is no risk of pregnancy.Educational measures are necessary in order to ensure that both the clinical community and patients are informed about the risks of valproate in pregnant women and women of childbearing age, and about the measures necessary to eliminate the risk of exposure on valproate in pregnancy.In this publication, only the material relevant to prescribers is mentioned. A full list of the educational materials can be found in the published assessment report .The development of an improved healthcare professional guide is due following the 2018 review. This guide will explain the PPP and its conditions. It will explain the requirements prior to starting treatment with valproate, the modalities for annual re-assessment of the need for valproate therapy, and discontinuation or switching to alternative treatment options for female children who experience menarche and women of childbearing potential.Recommendations on switching or discontinuing valproate treatment, as well as recommendations on pregnancy planning, will support provision of this information to patients.Actions to mitigate the risks associated with the use of valproate in case of pregnancy will also be included.This guide should allow prescribers to familiarise themselves with the more recent data on disorders of development in the exposed child, provide information about the risks of valproate monotherapy and poly-therapy and a description of the roles of different healthcare professionals. It should also provide instructions to the prescribers on the distribution of the patient guide and the completion of the risk acknowledgment form.As part of the PPP, an annual risk acknowledgment form will be made available to support the transmission of information to the patient and foster the dialogue between the prescriber and the patient. This form will ensure that the information has been given and that it is understood by the patient.The form will include a checklist for prescribers and patients (or carers). The checklist is intended to be used by physicians at the time of treatment initiation, and at the annual review to facilitate discussion with female patients about the suitability of valproate treatment and its risks.This acknowledgment form will cover information about the risk to the unborn baby in case of in utero exposure to valproate, the need for negative pregnancy test at treatment initiation, the need for effective contraception without interruption throughout the entire duration of treatment with valproate . It will also require that the patient contacts her physician once she decides to plan for a pregnancy, to ensure timely discussion of alternative treatment options prior to conception and before contraception is discontinued, and that she contacts her doctor immediately for an urgent treatment review in case of suspected or inadvertent pregnancy.The development of an improved guide for women who are being prescribed valproate and are able to get pregnant, is also in progress. Although this document is addressed to patients it is summarised here as treating physicians may be requested to provide this guide directly to their patient.The guide will provide comprehensive information on risks to the unborn child due to in utero exposure to valproate, the details of the PPP and the required actions in case of pregnancy or intention to become pregnant. In order to provide adequate information, it will address different situations in the patient journey and be age-appropriate: from first prescription, women continuing valproate treatment but not trying to have a child, women of childbearing potential continuing valproate treatment and considering trying to have a child, and pregnant women (unplanned pregnancy). Information about the annual risk acknowledgement form and the patient card which has also been developed should be included in the patient guide.Migraine and chronic headaches occur frequently in the population and more specifically in women. In case of pregnancy the treatment of migraine may be complicated due to the risk of certain medications. For the preventive treatments there are fewer options available to physicians.Valproate has a place in the pharmaceutical armamentarium for the prophylaxis of migraine attacks, according to several clinical guidelines.Valproate treatment should be initiated with caution in young females and women of child-bearing potential in view of the risks to the foetus in the event of exposure to valproate during pregnancy.In view of the risks for the unborn child when exposed to valproate in utero, valproate should only be used as last line medication for prophylaxis of migraine attacks in female children, adolescents and women of childbearing potential.Adherence to the PPP is essential. Pregnancy should be excluded before start of any treatment with valproate, and as appropriate later on. The patient should be counselled regarding contraception, but also assessed to ensure she can comply with the use of effective contraception without interruption during the entire duration of treatment with valproate. In case of unplanned pregnancy, valproate treatment should be discontinued as soon as possible. The information on the risks in case of an unplanned pregnancy should be explained to the patient at the first prescription and then at least annually for the duration of the treatment.Together, the clinician and patient should discuss the need for regular  review of her treatment by a specialist experienced in the management of migraine. This discussion should be documented via the risk acknowledgement form.The importance of the patient consulting her physician as soon as she is planning a pregnancy needs to be emphasised. This will enable a timely discussion to take place between the physician and the patient to ensure switching to alternative treatment options prior to conception and before contraception is discontinued.Clinical guidelines need to be reviewed and, potentially, updated to further improve the awareness of physicians on the risks of valproate.Finally, continuous interaction between the European Medicine Agency and European Headache Federation, as an eligible healthcare professional organisation dedicated to migraine, can facilitate the reduction of unnecessary exposure to valproate in migrainous women of childbearing age, via provision of better education materials for both physicians and patients suffering from migraine.


Accreditation for Gerontology Education Council (AGEC) is an organization that collaborates with, but is independent from the Gerontological Society of America and the Academy for Gerontology in Higher Education. It is directed by a Board of Governors consisting of nine members representing higher education gerontology programs and entities associated with the field of aging. The organizational structure also includes review teams, site visitors, and staff support. Higher education degree granting programs in gerontology, specifically associate arts degree, baccalaureate degree, and master’s degree programs, are eligible to apply to AGEC for accreditation. This symposium will have presentations that focus on Overview and Experiences to Date that will describe the accreditation process and what has been learned by the accreditation of the first three degree programs. The second presentation will focus on How and Why to Apply for Accreditation and will provide background information on the steps and processes necessary to submit for the accreditation review with clarification updates. The third presentation will provide lessons learned from our first reviews with suggestions on Preparing the Self- Study and will include guidance on approaches to be taken. The fourth presentation is also lessons learned with a focus on Mapping the Competencies as part of the Self Study. Symposium presenters share important information to encourage gerontology degree programs to apply for AGEC accreditation.


The included papers were identified by the scientific content committee from the American Orthotic and Prosthetic Association’s (AOPA) clinical content committee for the 2017 AOPA World Congress , as the top scientific presentations.The Journal of Neuroengineering and Rehabilitation (JNER. http://www.aopanet.org/education/aopa-world-congress/). The goal of this special topics edition was to afford the scientific and clinical communities the opportunity to take a “deeper dive” into the detail of the top presentations of the 2017 AOPA World Congress. These topics were regarded as cutting-edge topics ranging from exercise testing and cardiovascular events in patients with limb loss to gait assessment and novel therapies such as use of a virtual environment during rehabilitation. Additionally and importantly, economic evaluations for orthotic and prosthetic devices are also included.Presenters of the identified papers were invited to submit their full manuscript to the JNER for rigorous peer-review and consideration for publication in a special topic edition on prosthetics and orthotics that would capture the essence of the 2017 World Congress (Numerous stakeholders are responsible for facilitating development of this special issue of JNER. The guest editorial board wishes to thank AOPA and its volunteer content committee for vetting and identifying its top papers and presenters, the American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc. for its generous sponsorship, to the authors for submitting their work and of course to the JNER team for their partnership. It is our hope that the entire community of stakeholders in prosthetics and orthotics benefit from the findings contained in this edition of the JNER.We hope the findings will contribute meaningfully to the body of knowledge within prosthetics and orthotics and that they will assist in the reimbursement arena with clinical decision making and that others will build on and expand the findings and further push the boundaries of what can be achieved for those who use prosthetics and orthotics.


We have read with great interest the recent paper by Alhayek et al. . The aesIt is important that professionals treating patients with cleft lip and palate are aware of aesthetic assessment methods for analysis of results. However, this analysis has different models and combinations of evaluators and may use ordinal or analogue visual scales , althougThe study by Alhayek et al.  evaluateAnother important aspect of the study by Alhayek et al.  is the uIn addition to questions related to the aesthetics observed in the photographs, the evaluators answered two questions about the perception of the influence of cleft lip and palate on the social interactions and on the professional life. Questions related to quality of life have more closeness to the reality experienced when made to the patient himself. For what would be the criteria for the evaluator to answer about the influence of the cleft in the professional and social life of the five children?Alhayek et al.  used fouThe authors also report that discrepancies in the perception of facial aesthetics among evaluators could be attributed to different modalities and treatment protocols; however, it does not seem appropriate to conclude this using a small number of patients. These small caveats, however, do not take away the main relevant messages and discussion raised by Alhayek et al. .