Time Of First Visit Research Articles

A retrospective epidemiological study of delay for updated Thai red cross intradermal anti-rabies vaccination schedule amongst animal bite cases attending ARV clinic at a tertiary care centre

Background: Rabies is an acute viral disease, which causes encephalomyelitis in virtually all the warm blooded animals, including man. Almost 20000 deaths occur in India. The present study conducted with objective to analyze the delays and compliance for anti-rabies vaccination as per schedule and its some factors among the animal bite cases. Methods: Retrospective cross sectional record based study of cases attended Anti-Rabies Vaccination (ARV) clinic during the period of April 2012 to March 2013. The data extracted from records included socio-demographic variables, animal bite history treatment received and completion of ARV schedule. Data entered and analyzed using SPSS 21. Results: Total of 3548 animal bite cases attended the ARV clinic. Out of these cases, 18.2 %, 20.3% and 14.2% of cases not reported on scheduled date for 2 nd , 3 rd & 4 th dose of ARV respectively. Only 34.3% of cases completed the schedule. Delay for receiving ARV among women, cases from rural area & class II animal bite was statistically significant. Conclusions: Counselling regarding follow up of ARV schedule at the time of first visit to the anti-rabies vaccine clinic must be strengthened to avoid poor compliance and delaying of schedule.

Profile of patients seen at food allergy outpatient unit in the municipality of taubaté

Results In such period, 100 new patients were seen, mainly comprised of male (64%). Most patients (69%) were under 6 months old at the time of their first visit. In 41% of the patients, the first contact with cow’s milk protein occurred before 1 month old and only 21% had such contact after 6 months of age. One (1%) patient had symptoms with no direct exposure to cow’s milk (allergy linked to breast milk). Respiratory symptoms, whether alone or associated with other complaints, were the most frequent ones in 81% of the cases (rhinitis 32%), followed by dermatitis in 44% and vomiting in 20%. Patients assessed at first visit were on cow’s milk (LV) in 30%, soy milk 30%, breast milk (LM) 9%, partially hydrolyzed (PH) 11%, extensively hydrolyzed (EH) 9.5%, free amino acids (AA) 9.5% and 1 patient on calcium replacement. Following first evaluation, they were switched to: soy 35%, EH 30%, PH 22%, LV 6.5%, AA 6.5%, and LM 1%. At the time of first visit, 23.5% of patients on cow’s milk protein haven’t started treatment yet or were partially treated, thus requiring switch to another formula. Soy was properly indicated in 30% of patients, with no need for changing formula. In service experience, PH formula showed good results in patients whose relatives were atopic and/or oligosymptomatic. EH formulas were the most indicated ones (30%) at this first evaluation; therefore decreasing AA prescriptions (5.5%) which were below the numbers described in literature.

Waiting times in emergency department after using the emergency severity index triage tool.

Background:Hospital emergency departments (EDs) are as barometers of the health care system. Crowded EDs threaten delivery of timely care. Prolonged ED wait times reduce the quality of care and increase adverse and sometimes irreversible events.Objectives:The purpose of this study was to determine the patients' waiting time at Namazi and Shahid Faghihi hospitals in Shiraz, Iran.Patients and Methods:This analytical cross-sectional study was conducted in two phases from December 2012 to May 2013. First, the researcher attended the EDs of the two hospitals and recorded the information of 900 patients who entered the ED, including arrival time, level of triage, and time of first visit by physician. Then, among patients admitted to the ED units, 273 were followed and waiting times for the first physician order in the referral unit and the commencement of clinical interventions (defined as check time by the nurse) were recorded.Results:The median waiting time from arrival to first visit by physician for the 900 patients included in the study was 8 (5-14) minutes [median (interquartile range)]. For the patients admitted to referral units, waiting time was 84 (43-145) minutes for the physician order and 85 (45-147) minutes for the commencement of first clinical intervention; 75% of the patients in triage level I, 84.6% in triage level II, and 95.6% in triage level III were visited within the target time limit.Conclusions:Waiting time for commencement of clinical action in patients admitted to the EDs was considerably high for patients with higher priorities; so, rapid care of critically ill patients, identified during the triage process, should be emphasized.

Screening for violence risk factors identifies young adults at risk for return emergency department visit for injury.

Introduction:Homicide is the second leading cause of death among youth aged 15–24. Prior cross-sectional studies, in non-healthcare settings, have reported exposure to community violence, peer behavior, and delinquency as risk factors for violent injury. However, longitudinal cohort studies have not been performed to evaluate the temporal or predictive relationship between these risk factors and emergency department (ED) visits for injuries among at-risk youth. The objective was to assess whether self-reported exposure to violence risk factors in young adults can be used to predict future ED visits for injuries over a 1-year period.Methods:This prospective cohort study was performed in the ED of a Southeastern US Level I trauma center. Eligible participants were patients aged 18–24, presenting for any chief complaint. We excluded patients if they were critically ill, incarcerated, or could not read English. Initial recruitment occurred over a 6-month period, by a research assistant in the ED for 3–5 days per week, with shifts scheduled such that they included weekends and weekdays, over the hours from 8AM-8PM. At the time of initial contact in the ED, patients were asked to complete a written questionnaire, consisting of previously validated instruments measuring the following risk factors: a) aggression, b) perceived likelihood of violence, c) recent violent behavior, d) peer behavior, e) community exposure to violence, and f) positive future outlook. At 12 months following the initial ED visit, the participants' medical records were reviewed to identify any subsequent ED visits for injury-related complaints. We analyzed data with chi-square and logistic regression analyses.Results:Three hundred thirty-two patients were approached, of whom 300 patients consented. Participants' average age was 21.1 years, with 60.1% female, 86.0% African American. After controlling for participant gender, ethnicity, or injury complaint at time of first visit, return visits for injuries were significantly associated with: hostile/aggressive feelings (Odds ratio (OR) 3.5, 95% Confidence interval (CI): 1.3, 9.8), self-reported perceived likelihood of violence (OR 10.1, 95% CI: 2.5, 40.6), and peer group violence (OR 6.7, 95% CI: 2.0, 22.3).Conclusion:A brief survey of risk factors for violence is predictive of increased probability of a return visit to the ED for injury. These findings identify a potentially important tool for primary prevention of violent injuries among at-risk youth seen in the ED for trauma-related and non-traumatic complaints.

Factors affecting attendance at and timing of formal antenatal care: results from a qualitative study in Madang, Papua New Guinea.

BackgroundAppropriate antenatal care (ANC) is key for the health of mother and child. However, in Papua New Guinea (PNG), only a third of women receive any ANC during pregnancy. Drawing on qualitative research, this paper explores the influences on ANC attendance and timing of first visit in the Madang region of Papua New Guinea.MethodsData were collected in three sites utilizing several qualitative methods: free-listing and sorting of terms and definitions, focus group discussions, in-depth interviews, observation in health care facilities and case studies of pregnant women. Respondents included pregnant women, their relatives, biomedical and traditional health providers, opinion leaders and community members.ResultsAlthough generally reported to be important, respondents’ understanding of the procedures involved in ANC was limited. Factors influencing attendance fell into three main categories: accessibility, attitudes to ANC, and interpersonal issues. Although women saw accessibility (distance and cost) as a barrier, those who lived close to health facilities and could easily afford ANC also demonstrated poor attendance. Attitudes were shaped by previous experiences of ANC, such as waiting times, quality of care, and perceptions of preventative care and medical interventions during pregnancy. Interpersonal factors included relationships with healthcare providers, pregnancy disclosure, and family conflict. A desire to avoid repeat clinic visits, ideas about the strength of the fetus and parity were particularly relevant to the timing of first ANC visit.ConclusionsThis long-term in-depth study (the first of its kind in Madang, PNG) shows how socio-cultural and economic factors influence ANC attendance. These factors must be addressed to encourage timely ANC visits: interventions could focus on ANC delivery in health facilities, for example, by addressing healthcare staff’s attitudes towards pregnant women.

A collaborative outreach clinic for pregnant youth and adolescent mothers: Description of a pilot clinic and its patients.

To describe the pregnant youth and adolescent parents seen at an adolescent health outreach clinic in an urban community setting during a two-year pilot project. A retrospective chart review of all adolescents who presented at the monthly half-day clinics from January 2008 through January 2010 (n=36) was performed. Measures extracted from charts included demographic information, reason for referral, social history, mental health history and outcome of assessment. All participants were female (mean age 17 years). Forty-two percent were pregnant at initial assessment, while the remainder had one or two children, or a recent pregnancy loss. Sixty-one percent had no primary care physician. The primary reason for referral was mental health concerns, most commonly depression. Almost one-half of patients relied on social assistance and almost one-third were living in shelters. At the time of first visit, 42% of patients were not attending school; the highest level of school completed for most patients was grade 8. The majority had a history of mental health issues and previous drug and/or alcohol use. Adolescents presenting to the clinic had a history of disadvantage in terms of income, educational attainment, living arrangements and mental health background, and are in need of various health services including primary care practitioners. These findings will help to inform future program development for these vulnerable youth, and have implications for practitioners caring for this population.

Brain atrophy and disability progression in multiple sclerosis patients: a 10-year follow-up study

To identify MRI biomarkers associated with long-term disability progression in patients with multiple sclerosis (MS), and to define the rate of evolution of global, tissue-specific and regional atrophy in patients with MS over long-term. MRI of the brain and clinical neurological assessment was performed in 81 patients at time of first visit and after 5 and 10 years of follow-up. MRI was acquired on 1.5 T scanners. T1-lesion and T2-lesion volumes (LVs) were calculated. Global and tissue-specific atrophy changes were longitudinally assessed, using a direct measurement approach, by calculating percentage volume changes between different time points. Regional tissue volumes for the subcortical deep grey matter (SDGM) structures were also obtained. Disability progression was defined as an increase in Expanded Disability Status Scale of ≥ 1.0 compared to baseline at 5-year and 10-year follow-up. Over 5 years, patients with disability progression showed significantly increased loss of whole brain (-3.8% vs -2.0%, p<0.001), cortical (-3.4% vs -1.8%, p=0.009) and putamen volume changes (-10.6% vs -3.8%, p=0.003) compared to patients with no disability progression. No significant change in white matter (WM) volume was observed when comparing progressing and non-progressing patients. Over 10 years, there was a trend for greater decrease in whole brain volume (-5.5% vs -3.7%, p=0.015) in the progressing patients. No significant changes in LV measures were detected between the patients with and without disability progression. This long-term study shows that whole brain, cortical and putamen atrophy occurs throughout the 10-year follow-up of this MS cohort and is more pronounced in the group that showed disability progression at 5, but not at 10 years of follow-up. Overall, GM atrophy showed better association with disease progression than WM atrophy over 5-year and 10-year follow-up.

Differences between Italian and foreign women in the use of antenatal care

The number of foreigners inItalyhas been steadily growing over the last decades. This trend is accompanied by a parallel increase of the number of new-borns who have foreign parents. The aim of the present study is to compare the access and the adequacy of antenatal care for both Italian and foreign women, by controlling for demographic and socio-economic characteristics. Our source is the Certificates of Healthcare at Delivery (2003). Three appropriate indicators of frequency and adequacy of antenatal care have been constructed: 1) time of first visit; 2) number of visits and 3) number of scans. The factors which influence Italian and foreign womens’ access to antenatal care have been identified by using multinomial logistic regression models, in which time of the first visit is the dependent variable. Regarding healthcare received during the pregnancy, we show that strong inequalities in terms of both promptness and level of care persist between Italian and foreign women. Foreign women, particularly those without residency,- experience a delay in their first interaction with antenatal care services. The results of the present study prompt us to question the effectiveness of the policies for providing information to foreign women. Francesca LARICCIA, Researcher, ISTAT, Rome, Italy. E-mail: la riccia@istat.it . Eleonora MUSSINO, Researcher, ISTAT, Rome, Italy. E-mail: eleonora.mussino@gmail.com . Antonella PINNELLI, Professor of Demography, Sapienza University of Rome. E-mail: pinnelli.antonella@gmail.com . Sabrina PRATI, Researcher, ISTAT, Rome, Italy. E-mail: prati@istat.it .

What is the usefulness of the fragmentation pattern of the femoral head in managing Legg-Calvé-Perthes disease?

BackgroundWithin the lateral pillar classification of the Legg-Calvé-Perthes (LCP) disease, hips seem quite variable in the pattern of fragmentation as seen in radiographs. The purpose of this study was to determine: if it is possible to reliably subdivide the lateral pillar groups into femoral head fragmentation patterns, and if such a subdivision of the lateral pillar groupings is clinically useful in managing LCP disease.MethodsTwo hundred and ninety-three anteroposterior radiographs taken at the maximal fragmentation stage (189 lateral pillar B, 57 B/C border, and 47 C hips; mean bone/chronologic age at the time of first visit, 6.2/7.9 years) and at skeletal maturity (mean age, 16.6 years) were analyzed. We distinguished 3 fragmentation patterns in each pillar group based on the region of major involvement. We tested the inter- and intraobserver reliability of our classification system and analyzed the relationships between the fragmentation patterns and the Stulberg outcomes as well as other factors such as surgical treatment and age.ResultsInter- and intraobserver consistency in fragmentation pattern assignments was found to be substantial to excellent. A statistically significant trend (p = 0.001) in the proportion of Stulberg III or IV outcomes in comparison with Stulberg I and II was only found for the different fragmentation patterns in our lateral pillar B patients: fragmentation patterns having mainly lateral-central necrosis led to poor outcomes. No significant association was found between fragmentation patterns and Stulberg outcomes in pillar groups B/C border and C.ConclusionsOur results are consistent with the lateral pillar classification itself. Therefore, fragmentation patterns in each lateral pillar classification did not provide clinical usefulness in the management of LCP disease.

Non-surgical Management in Idiopathic Granulomatous Mastitis

Introduction: Idiopathic Granulomatous Mastitis; Despite its low incidence, is in high interest due to masquerading as carcinoma of the breast. In confirmed IGM case series, it`s been reported that more than 50% of patients were initially misdiagnosed as affecting by carcinoma of the Breast. Herein we are introducing a non-surgical management of IGM with frequently aspiration of the masses accompanied by using bacteriostatics and close regular surveillance. Material and Method: This was a before and after clinical trial looking at the effects of repeated aspirations coupled with antibiotic treatment on the natural course of IGM. Overall 55 patients met the inclusion criteria. These patients underwent clinical and imaging study as well as Core Needle Biopsy (CNB) of the lesion with a 14-16 Gauge needle. Patients` presenting sign and symptoms were categorized into six variable ones, including inflammation, Erythma, mass, pain and sinus formation. Confirmed cases of IGM were treated with antibiotic therapy (Ciprofloxacin 500 mg, or Trimethoprin-Sulfamethoxazol 400+80 mg every 12 hours) until either the relief of symptoms or a maximum of 3 weeks. One or two Weeks follow up visits were conducted in the first three months, monthly visits in the first six months, and then no matter when the last visit was done, it was recorded. Results: 44 patients (80% of cases), elucidated signs of inflammation, whereas solely 18 patients (32% of cases) were presented with inflamed breasts at final visit. (P value=0.03) 45 patients (81% of cases) presenting symptom was erythema, ultimately there were 14 cases (25%) in whom erythema persists. (p value=0.03) Mass presence was the dominant sign being discovered in 45 (72%) of enrolled cases at the time of first visit. The reported results has experienced a decline curve, finally 10 cases (18%) has remained symptomatic with a mass. (P value=0.02) Furthermore pain was elucidated in more than half of those who entered the study, 25 cases (56%). Sinus formation has complicated 14.5% (8 cases) of the patients, interestingly followed by a minimal rise at second visit during 1-3 weeks, the number of affected patients was consistently reported as 7 patients (12%) during the further visits. Discussion and Conclusion: Because of the nature of the disease which is an inflammatory reaction, any form of surgical intervention will be an unsuitable procedure and may become a disaster for both patient and the physician. As a result, the procedure of recurrent drainage may resolve the symptoms of pain, erythema and possibly the sinus formation, ultimately the mass will be resolved; therefore the recurrent drainage is highly recommended.

SAT0312 Psoriasis and psoriatic arthritis among natives and mestizos from the andean mountains region of peru

BackgroundPrevious epidemiological studies described that both Psoriasis (Ps) and Psoriatic Arthritis (PsA) are diseases with negligible prevalence among Natives from the Andean mountains of Peru. We herein first report the...

Ultrasound monitoring of cervical canal length combined with measurement of fibronectin in cervical secretion for predicting preterm delivery

The length of cervical canal was monitored by perineal ultrasonography in 377 pregnant women with 22 to 36 weeks of gestation, at the same time the contents of fibronectin (fFN) in cervical secretions were measured. The rate of cervical canal length shortening from the time of first visit to the appearance of preterm signs was calculated. When the cervical length shortening rate was 16%~60%, fFN (+) was correlated with higher preterm birth rate (P 60% there was no significant difference in preterm delivery rate between fFN (+) and fFN (-) groups (P>0.05). The results indicate that the monitoring of cervical canal length combined with fiberonectin measurement in cervical secretion may better predict preterm birth. Key words: Fibrin; Preterm birth

KRAS Mutation in Patients with Lung Cancer: A Predictor for Poor Prognosis but Not for EGFR-TKIs or Chemotherapy

The prognostic and predictive value of KRAS mutations in patients with lung cancer is controversial. Biases in disease stage, treatment regimen, small-scale patient studies, and biomarker status have led to inconsistent results in previous reports. The KRAS and EGFR genes were examined in 1935 consecutive patients with non-small cell lung cancer. All patients were divided into KRAS mutation (KRAS group), EGFR mutation (EGFR group), and KRAS/EGFR wild type (WT group) groups. Randomly selected cases were paired with patients with the KRAS mutation, the EGFR mutation, and KRAS/EGFR wild type patients according to tumor, node, metastasis stage, time of first visit within 1year, and pathology. Progression-free survival (PFS) and overall survival were evaluated by Kaplan-Meier and Cox models. The KRAS mutation rate for lung adenocarcinoma was 5.90%. The overall survival was 14.47, 20.57, and 42.73months for the KRAS group, WT group, and EGFR group, respectively (P<0.001). Multivariate analysis indicated that KRAS mutation status was an independent prognostic factor (hazard ratio 2.69, 95% confidence interval 1.91-3.80, P<0.001). No difference was found in PFS and tumor responsiveness between patients with a KRAS mutation and those with wild type KRAS/EGFR for chemotherapy and EGFR tyrosine kinase inhibitors (TKI). PFS did not significantly differ for chemotherapy among the three groups (P=0.270). KRAS mutation is a poor prognosis factor, but it is not an independent predictor of response to EGFR-TKI or chemotherapy in patients with lung cancer.

Recent Incidence of Trisomy 21 in a Japanese Hospital

Trisomy 21, the chromosome abnormality responsible for over 95% of Down syndrome, is one of the most common conditions encountered in the genetic clinic. Recently, the increasing share of pregnancies with advanced maternal age and its impact on the increased incidence of trisomy 21 have been reported in the United States [1-3]. Our hospital is one of main perinatal centers in Tokyo, Japan (about 2,100 deliveries per year). In this study, we examined the recent incidence of trisomy 21 associated with maternal age at our hospital. We reviewed the obstetric records of all Japanese singleton pregnancies at our hospital form January 2005 through January 2011. Demographic information and the characteristics of labor were extracted from patient charts. The conditions of the study patients were Japanese singleton pregnancies whose estimated date of delivery were from January 2006 through December 2011 and managed from 14 weeks or earlier at our hospital. In this study, thus, we have excluded the cases as follows (1) multifetal pregnancies, (2) non-Japanese pregnancies, (3) the time of first visit of our hospital at ≥ 15 weeks’ gestation, and/or (4) spontaneous fetal demise before 22 weeks’ gestation. We examined the maternal age at age of the estimated date of delivery. There were 28 cases of trisomy 21 in 10964 Japanese singleton pregnancies (1/392). In our hospital, there were 39 cases of trisomy 21 in total during this period; however, there were 8 cases of trisomy 21 refereed to our hospital at ≥ 15 weeks’ gestation due to fetal abnormality, 2 non-Japanese cases of trisomy 21 and 1 case of trisomy 21 in twin pregnancy. During this period, the average maternal age of all pregnancies was 32.3 ± 5.5 years old and 35% of the mothers were 35 years old or more at the estimated date of delivery; while the average maternal age in the cases with trisomy 21 was 38.0 ± 4.7 years old. The incidence of trisomy 21 in cases of maternal age of < 35 years (3 cases, average: 27.7 ± 3.5 years), 35 39 years (15 cases, average: 37.5 ± 1.1 years) and ≥ 40 years (10 cases, average: 41.7 ± 1.9 years) were 1/2364, 1/209 and 1/74, respectively. These incidences by maternal age were almost similar to those reported previously in the United States [4]. Of the 28 cases of trisomy 21, 11 cases (39%) were diagnosed as trisomy 21 prenatally using amniocentesis due to maternal request. Ten cases of them (91%) were artificial aborted; thus, the incidence of live births with trisomy 21 was 1/608 (18 cases). The average maternal age in the cases diagnosed prenatally was significant higher than that diagnosed postnatelly (40.1 ± 3.3 vs. 36.6 ± 5.0 years, p < 0.01 by unpaired t-test). The tendency is also similar to that reported in the United States [1-3]. In conclusion, in Japan the recent increased share of pregnancies with advanced maternal age seemed to contribute to the increased incidence of trisomy 21 as observed in other countries.

Haemoglobin Status Of Pregnant Women An Analysis Of 1804 Cases

Introduction: Anaemia is a very common finding in Bangladeshi women. This is more common in pregnant women. Timely meet up of nutritional need successfully prevents the development of anaemia during pregnancy. Method: A cross-sectional and multi-centre study was carried out among 1804 pregnant cases at Child Welfare Centre (CWC) of Combined Military Hospitals (CMH) of Comilla, Savar and Bogra cantonments over a period of 19 months. Irrespective of ages all pregnant women who attended CWCs for routine ante-natal check up and whose blood haemoglobin level was known at the time of first visit were included in this study. Pregnant women with diabetes mellitus, hypertension and any congenital haemoglobin disorders were excluded from this study. Objectives: The aim of the study was to find out the haemoglobin levels in pregnant women in defence community from different parts of Bangladesh. Result: Total 1804 women were included as per inclusion criteria. Their mean (±SD) age was 28.1±13 years and the range was 19-41 years. Haemoglobin level during pregnancy was estimated and 229 (12.7%) of the pregnant women were observed anaemic. Most of the women had reported in the third trimester (40.8%) followed by second trimester (33.4%) and then first trimester (25.8%). Iron supplement was given to both normal and anaemic pregnant women. Conclusion: The study showed that prevalence and severity of anaemia in pregnant subjects attended CWCs for antenatal check up were exceptionally low. This indicates that consciousness regarding taking care of pregnant women of the community studied was satisfactory. DOI: http://dx.doi.org/10.3329/jafmc.v7i2.10390 JAFMC 2011; 7(2): 18-20

Abstract 2634: A Prospective Study Of Asymptomatic Intracranial Arterial Stenosis In Japanese Healthy Subjects

Background and purpose: Atherosclerotic stenosis of major intracranial arteries accounts for 5 to 10% of all causes of stroke. The Warfarin versus Aspirin Symptomatic Intracranial Disease (WASID) Study has demonstrated stroke onset in 5 among 100 patients with asymptomatic intracranial arterial stenosis (AIAS) during the follow-up period of 1.8 years. However, there are no prospective studies of intracranial stenosis in healthy subjects with a longer follow-up period. We conducted a 7-years longitudinal study in healthy subjects with AIAS to examine its risk factors and prognosis. Methods: We performed a prospective study on 3,155 neurologically normal subjects without history of stroke (1724 men, 1431 woman, mean age of 59). They were followed up with the mean interval of 83 months to obtain information about their stroke event with a questionnaire by mail or telephone interview and inquiry to the relevant medical facilities. AIAS were assessed on MRA at the time of first visit for all subjects. Result: AIAS was detected in 323 subjects (10.2%; AIAS group) at the initial examination. Significant risk factors for AIAS were older age, female, hypertension, high values of fasting blood glucose and HbA1c. During the follow-up stroke occurred in 77 subjects (2.7%) from the no-AIAS group and 14 subjects (4.3%) from the AIAS group (p = 0.07). Age and sex affected the stroke onset. The Cox's proportional-Hazards regression model after adjustment of age and sex revealed the significant contribution of AIAS on stroke onset (OR 1.9; 95% CI 1.03-3.4, p = 0.039). The stroke types were 11 ischemic and 3 hemorrhagic in the AIAS group. Conclusions: AIAS is a significant risk factor for future stroke even in healthy subjects. Intense management of blood pressure and glucose level might be crucial for preventing asymptomatic intracranial atherosclerotic disease.

Quality of Prenatal Care Services in Karabuk Community Health Center

The aim of the study was to evaluate the quality and quantity of prenatal care services according to gestastional week in Karabuk Community Health Center (CHC). Methods: In this descriptive study 365 pregnant women was selected as sample among 753 pregnant women registered at Karabuk CHC in 18/01/2011. 93.0% of women in the selected sample has been visited in their homes and the face to face interviews were done. The questionnaire was prepared according to Prenatal Care Management Guidelines (PCMG) of Ministry of Health. Findings The number of follow-ups was not complete in 23.7% of 15-24 month, 34.4% of 25-32 month, 52,1% of 33-42 month pregnant women. At least four follow-up visits were completed only in 66,7% of postpartum women. Timing of first visit was after 15th week in 15,6% of women. In follow up visits 62.5% of of women’s height were never measured, in 13,0% the women hearth sound of infants didn’t monitored at least once. Laboratory test numbers were under the level required by PCMG. The delivery conditions weren’t planned in 41,8% of last trimester and postpartum women and training about breastfeeding wasn’t given to 15,5 of the same group. Result In family medicine model in Karabuk CHC developments in number of prenatal follow-up visits were observed, but no substantial improvements were found in quality of prenatal visits. Regular in service trainings shoud be given to family doctors and midwives. The use of prenatal care guideline published by MoH should be increased. Keywords: Prenatal care, pregnancy, timing of first visit, qality of prenatal care

Ultrasonographic Quantitative Estimation of Hepatic Steatosis in Children With NAFLD

The diagnostic accuracy of hepatic ultrasonography (US) for detection and grading of hepatic steatosis in children with suspected nonalcoholic fatty liver disease (NAFLD) remains poorly characterized. The aim of this study was to prospectively evaluate the clinical utility of ultrasonographic quantification of hepatic steatosis. Our cohort consisted of 208 consecutive pediatric patients with biopsy-proven NAFLD. Hepatic US was performed within 1 month of the liver biopsy procedure. Steatosis identified by US was scored using a 0 to 3 scale based on echogenicity and visualization of vasculature, parenchyma, and diaphragm, and compared to histological features based on Brunt's classification. The median age at time of first visit was 10.8 years and 64% were boys. Sixty-nine percent had moderate to severe steatosis on histology. Ultrasonographic steatosis score (USS) had an excellent correlation with histological grade of steatosis (with a Spearman's coefficient of 0.80). The area under the receiver operating characteristic curve for ultrasonographic detection of moderate-to-severe steatosis was 0.87. The USS did not correlate significantly with inflammatory activity or fibrosis stage; however, there was significant correlation with the NAFLD activity score (NAS), albeit this was in large part the result of the strong correlation with the steatosis component of NAS. Serum alanine transaminase and aspartate transaminase were not associated with histological grade of steatosis and showed no correlation with USS. Our results, which represent the largest prospective pediatric study evaluating the role of hepatic US in children with biopsy-proven NAFLD, demonstrate the utility of this technique for noninvasive diagnosis and estimation of hepatic steatosis in children.

Effect of Media Warnings on Rabies Postexposure Prophylaxis, France

Effect of Media Warnings on Rabies Postexposure Prophylaxis, France

Icodextrin-associated hepatotoxicity.

Sir, Abnormal liver function tests can be observed in peritoneal dialysis (PD) patients. The most common cause of these are viral infections, especially hepatitis B and C [1]. Icodextrin-based PD solutions (Extraneal; Baxter, IL, USA) are increasingly used in this patient population [2]. Several adverse reactions have been reported with icodextrin, mainly skin reactions (upto 15%) [3]. In the full prescription catalogue, it is said that it may lead to liver dysfunction, specifically alkaline phospahatase (ALP) and alanine transaminase (ALT) levels. A 26-year-old male PD patient applied to our Transplant Unit to undergo renal transplantation from his mother. He had been on PD for the last 2 months and was treated with a 13 L of 1.36% glucose-containing PD solution and 2 L of Extraneal exchange. He was also on 80 mg/day furosemide. At the time of first visit, he had exfoliative eruptions on his back. Except for high ALT (295 mg/dL, normal <45) and ALP levels (390 mg/dL, normal 35–140), all other liver function parameters were normal. He did not have a history of liver disease and his liver function tests were normal until 2 months ago. His HbsAg, Anti-Hbs, Anti-Hbc, Anti-CMV IgM, Anti-EBV IgM antigen were negative and Anti-CMV IgG and Anti-EBV IgG were positive. Hepatitis C virus was confirmed to be negative by real-time polymerase chain reaction. Alpha-trypsin, ceruloplasmin and autoimmune marker levels were normal. Liver ultrasonography was normal with normal size, paranchyme and echogenity, gall bladder and bile duct was normal. Since there were no evident infectious, metabolic and toxic findings, the decision was made to perform a liver biopsy. However, the patient refused to undergo liver biopsy. After review of the literature on skin lesions and hepatic dysfunction in dialysis patients, we thought that both these signs (eruption and liver dysfunction) may be related to icodextrin use. As a trial and error approach, it was decided to discontinue icodextrin. On Day 3 of discontinuation, ALT levels decreased from 295 to 133 and on Day 11 to normal levels. Similarly, ALP levels decreased from 390 to 260 on Day 11. His previous ALT levels are depicted in Figure 1. Also, exfoliative eruptions disappeared. This trial and error approach showed that the icodextrin-based PD solution was the cause of liver dysfunction. The patient is now transplanted and his liver enzymes continue to be normal. Fig. 1. Serum ALT levels upon icodextrin use and discontinuation. Liver dysfunction was incidentally diagnosed in this case during his preoperative workup for renal transplantation. After exclusion of metabolic disorders, infectious agents, alcoholism and other causes of liver dysfunction, the focus was directed to prescribed drugs. Review of the literature directed us toward icodextrin-based PD solution while it has been linked to skin lesions in PD patients which was also present in our case. However, no valid data exists regarding liver dysfunction with icodextrin-based PD solution. Our trial and error approach showed that it was indeed related to this. Icodextrin is reported as relatively safer compared to glucose-based PD solutions regarding adverse and side effects. The pathophysiological mechanisms underlying liver dysfunction with icodextrin use is unclear. Drug-induced hepatotoxicity can be due to various mechanisms: disturbances in intracellular ion shifts, bile duct injury, apoptosis, mitochondrial dysfunction and direct liver immune injury [4]. Which one/ones of these is responsible for icodextrin-related damage needs to be clarified. As a conclusion, icodextrin may lead to hepatotoxicity, this may be more common than anticipated and shall be taken into account in the differential diagnosis of liver test abnormality in PD patients.