Open Access Policy Article

The Demography Myth: How Demographic Forecasting Underestimates Hospital Admissions, and Creates the Illusion that Fewer Hospital Beds and Community-based bed Equivalents, will be Required in the Future

Neeraj Beeknoo, Rodney P. Jones

Journal of Advances in Medicine and Medical Research, Page 1-27
DOI: 10.9734/BJMMR/2017/29984

Aims: This Policy Article, which includes data synthesis, seeks to evaluate the effectiveness of demographic-based forecasting of future hospital admissions, and hence for hospital bed numbers. A role for the absolute number of deaths, as a proxy for persons approaching the end-of-life, will also be investigated, especially as this is the principle factor behind the volatility in bed occupancy.

Study Design: Literature review plus supporting analysis of relevant trends.

Place and Duration of Study: Studies from a variety of countries, analysis of data relating to the NHS in England, additional analysis relating to the Kings College Hospital, London.

Findings: Demographic forecasting is subject to the constant risk fallacy, namely, admission rates are changing over time. A variety of factors can be seen to lead to changes in admission rates. There is strong evidence that it is the trend in the absolute number of deaths, rather than demography which drives most of the marginal changes in bed demand. Up to 55% of a person’s lifetime bed utilization may occur in the last year of life. However, the ratio of deaths per 1,000 population ranges from 4 to 16 (inner city communities to more rural and retirement locations). Deaths per GP also ranges between 5 to 27, while the crude mortality rate in English hospitals ranges from 1.3% to 5.4%. These imply that in some locations end-of-life has a greater impact not only on primary, secondary and social care resources, but also on the volatility in resource requirements. There are 20 deaths per GP in the Torbay integrated health and social care organization indicating that the 30% fewer bed days per death achieved in this organization may not be replicated elsewhere. Same-day-stay admissions require separate forecasts since they rely on technological trends driving day surgery rates (elective admissions) and the need for observation and rapid diagnosis in medicine (both elective but mainly emergency admissions). In England, an obsession with fewer beds on behalf of the Department of Health (now NHS England) has been a key factor bringing the NHS into crisis. The worst affected hospitals now run at close to 100% average occupancy. However, the period 22 weeks prior to death appears to mark a watershed for acute care, where surgical, medical and critical care interventions become increasingly futile. A shift to a more palliative-based model of non-acute care is recommended, and will lead to considerable savings in occupied beds. A new generation of models are desperately required, as are supporting biochemistry, vital sign and frailty-based algorithms to enable care to be diverted out of acute hospitals during the last weeks of life.

Open Access Original Research Article

Evaluation of Periodontal Tissues and Abdominal Aorta of Rats with Induced Obesity by Monosodium Glutamate and Experimental Periodontitis

Karine Figueredo da Costa, Maria Lúcia Bonfleur, Viviane Pontillo, Stefany Pedrotti, Paula Bernardon, Rose Meire Costa Brancalão, Celia Cristina Leme Beu, Patricia Oehlmeyer Nassar, Carlos Augusto Nassar

Journal of Advances in Medicine and Medical Research, Page 1-14
DOI: 10.9734/BJMMR/2017/30165

Introduction and Aim: The aim of this study was to evaluate the behavior of experimentally-provoked-periodontitis tissues and the abdominal aorta in rats with acquired induced hypothalamic obesity.

Methods: Initially in the first 5 days of life, a cohort of twenty-eight male Wistar rats were divided into 2 groups; the first group [n=14] were given intradermal injections of 4 G/kg of solution of Monosodium glutamate (MSG); the second group [n=14] was given 1,25 G/kg/day of saline solution (group CTL) in the cervical region. At 70 days, each of the two groups were further divided into another 2 subgroups, and periodontitis was induced with ligature placing as the experimental variable, on the 1st lower molars, except in group 1 and 3. This created 4 groups: (1) control group without ligature (CTL n=7); (2) control group with ligature (CTLLIG n=7); (3) group MSG without ligature (MSG n=7); (4) and group MSG with ligature (MSGLIG n=7). Total n=28. After 100 days the rats were sacrificed and gingival tissue, abdominal aorta samples, and a hemi-mandible were dissected out for immunological, morphological and radiographic analysis.

Results: Both Radiography and histopathology showed significant lower alveolar bone loss when the MSGLIG, group was compared to the CTLLIG group (p< 0.05). In the abdominal aorta morphometric analysis there was statistically significant difference in the measurement of the thickness of the aortic wall, being the largest thickness observed in the MSGLIG group (p< 0.05).

Conclusion: Therefore, this study suggests that the periodontitis in association with the hypothalamic obesity may contribute to the increase of the width of the abdominal aorta walls, as well as the hypothalamic obesity may exert a protective effect on alveolar bone loss.

Open Access Original Research Article

Role of Liver Biopsy in HBV Infected Egyptian Patients: A New Insight

Khaled Gameel, Maha M. Elsabaawy, Madiha Naguib, Nermine Ehsan, Dina Alazab, Mohsen Salama, Eman A. Rewisha

Journal of Advances in Medicine and Medical Research, Page 1-13
DOI: 10.9734/BJMMR/2017/29830

Background: In chronic hepatitis B (HBV) Egyptian patients; international guidelines showed a wide discrepancy in validity of liver biopsy as a prerequisite to solve the dilemma of whether to start treatment or not.

Aim: Evaluating role of liver biopsy in deciding to treat or not Egyptian patients with chronic HBV irrespective of HBV-DNA and/or ALT levels.

Methods: This prospective study was carried out on four equal groups of chronic HBV Egyptian patients, selected from viral hepatitis clinic, National Liver Institute, Menofia University. They were classified according to their HBV DNA and ALT levels. All patients were HBsAg positive for at least 6 months, detectable HBV-DNA by PCR, with no prior submission for antiviral regimens. Liver biopsy was performed and analyzed according to Metavir scoring systems.

Results: Patients were 32.2 years old with 87.3% male prevalence. 88% of patients were HBeAg negative with 22% showing significant pathology {fibrosis (F) ≥2 and/or necroinflamatory activity (A) ≥2}. Patients eligible for treatment according to EASL 2009 guidelines were 39%, decreased to 29% with implementation of high ALT versus 22% when treatment decision was based on liver biopsy. While only 10.7% were eligible for treatment according to ASSLD 2009 guidelines, decreased to 4.3% with implementation of high ALT levels versus 22.3% when treatment decision was based on liver biopsy findings.

Conclusion: In spite of the discrepancy between treatment indications using either EASL 2009 or ASSLD 2009 guidelines, liver biopsy was more reliable in deciding which chronic HBV Egyptian patients to be treated, irrespective of HBV-DNA and/ or ALT level.

Open Access Original Research Article

Ultrastructure of Mugil brasiliensis Teleost Retina I: Cones, Rods, Horizontal, Bipolar, Piriform Amacrines, Tubular Cells, Undulate Amacrine Cells, Outer and Inner Plexiform Layers

Jose Antonio O'Daly

Journal of Advances in Medicine and Medical Research, Page 1-16
DOI: 10.9734/BJMMR/2017/30371

Aims: To analyze the ultrastructure of cones, rods, horizontal, bipolar and amacrines cells from Mugil brasiliensis teleost retina as well as all the connections found between the cells.

Methodology: The retina was fixed with glutaraldehyde and osmium tetroxide and radial and tangential sections stained with lead citrate and uranyl acetate to be analyzed in a Hitachi 11B electron microscope at 75 Kv.

Results: Horizontal cells had finger like process reaching the outer plexiform layer ending in cone and rod invaginations, and also lateral unions between plasma membranes, forming a net, with a functional contact between them. Bipolar cells were radially oriented with dendrites branching in the outer plexiform layer contacting cones and rods and lower terminals branching in the inner plexiform layer. Stellate amacrine cells send ascendant process to the outer plexiform layer and form a continuous net below horizontal cells. A new layer named tubular cells was described by the first time below internal horizontal cells forming a net. Undulate amacrine cells around bipolar cells were also described by the first time. Cones and rods terminals had ascendant expansions of horizontal and bipolar cells in a triad structure around the synaptic band. Piriform amacrine cells were described with dark cytoplasm due to numerous glycogen granules and with clear cytoplasm with scarce glycogen granules, both sending prolongations to the inner plexiform layer.

Conclusion: This paper is a comprehensive analysis of ultrastructure of seven retinal cells, finding two new cells in teleost retina, 1- tubular cells forming an extensive tangential net below internal horizontal cells, with characteristic structures not seen in the literature on retina before and, 2- undulate amacrine cells that surrounds many bipolar cells across the retina. Functional contacts structured by bilaminar membranes were found between digital terminals of horizontal cells and bipolar cells in rods and cones, between bipolar dendrites, tubular cells, stellate amacrine cells, piriform amacrine cells, as well as between lateral expansions of horizontal cells.

Open Access Original Research Article

Relationship between the Anterior Fontanel Size and Occipito-frontal Circumference

Elizabeth-Martha C. Okorie, Peace I. Opara Peace, Nwadiuto A. Akani, Edward A. D. Alikor

Journal of Advances in Medicine and Medical Research, Page 1-10
DOI: 10.9734/BJMMR/2017/27446

Aims: To determine the relationship between Anterior Fontanel size (AF) and the Occipito-frontal circumference (OFC).

Study Design:  A cross sectional and analytical study of Nigerian newborns and infants.

Place and Duration of Study: Post-natal ward, Special care Baby Unit and Well Infant Clinics of the University of Port Harcourt Teaching Hospital (UPTH) and Braithwaite Memorial Specialist Hospital (BMSH) Port Harcourt, Nigeria. Duration: 10 weeks, between October and December 2011.

Methodology: This is a Cross sectional observational and analytical study of 2895 subjects recruited serially at the Post-Natal Wards and Special Care Baby Unit (SCBU), University of Port Harcourt Teaching Hospital, (UPTH); and the Well Infant Clinics of UPTH and Braithwaite Memorial Specialist Hospital (BMSH), Port Harcourt, Nigeria. AF sizes were measured in newborns at birth and at 6, 10 and 14 weeks; 6, 9, 12, 18 and 24 months of age respectively using a modified version of Faix’s method.

Results: There were 1391 males and 1504 females giving a male: female (M:F) ratio of 1:1.1. AF sizes decreased significantly with increasing post-natal age, p < 0.001. The reverse was the case with OFC which increased significantly from birth to 24 months of age. A strong negative correlation was observed between AF size and OFC with increasing postnatal age.

Conclusion: A statistically significant negative correlation exists between AF size and OFC. This relationship can be represented mathematically by the formula: AF size = 14 - OFC (0.265).

Open Access Original Research Article

Immune-modulatory Effect of Ionizing Radiation on Type 1 and Type 2 Immune Responses among Workers in Cardiac Catheterization Units

Sahar Ali Farahat, Neveen Mansour, Marwa Sheta, Mona Abdallah Ramadan

Journal of Advances in Medicine and Medical Research, Page 1-10
DOI: 10.9734/BJMMR/2017/29663

Introduction: It has long been known that ionizing radiation induced damage of the immune system. However, substantial evidence suggests more varied effects of radiation on the immune system, prompting the re-characterization of radiation as ‘immune-modulatory’ rather than immune-suppressive.

Objective: This study aimed at investigating the effect of occupational exposure to ionizing radiation on the immune system, particularly the effect on the balance between type 1(Th1) and type 2(Th2) immune response.

Methods: A group of 47 cardiac catheterization workers (19 physicians,15 nurses and 13 technicians) and another 47 job, age, and sex  matched controls were subjected to investigating the level of Th1 cytokines (IL2, INFγ), Th2 cytokines (IL10) and CD4%. Annual personal exposure was monitored by TLD (thermoluminescent dosimeter) readings over the last 3 years

Results: Dosimeter readings were within the acceptable level over the last three years preceding to the study. There is statistically significantly higher level of Th1 cytokines (IL2, IFNγ) along with statistically significant lower levels of Th2 cytokines ( IL10) associated with lower CD4% among the exposed compared to control groups (P<0.05). Significant positive correlation was detected between the mean TLDs readings and each of IL2 (r=0.617 P<0.001) and IFN γ (r= 0.560 P<0.001). On the other hand, significant negative correlation was detected between mean TLDs readings and CD4% (r= -0.312 p<0.05). ANOVA and Post Hoc tests showed significantly higher level of Th1 cytokines with significantly lower levels of Th2 cytokines and CD4% among the physicians compared to control group

Conclusion: Occupational exposure to low dose ionizing radiation induce switch of the immune system to Th1 immune response.

Open Access Original Research Article

Relationship between the Inclination of Adjacent Teeth Caused by Vertical Malposition of the Second Primary Molar – in Relation to Development Stage of First Molar

Shoji Takahashi, Shigeru Watanabe, Koji Watanabe, Akihiro Nakamura, Reina Odai, Takashi Sasabe

Journal of Advances in Medicine and Medical Research, Page 1-9
DOI: 10.9734/BJMMR/2017/29480

Aims: Mesial inclination of first molar caused by vertical malposition of the second primary molar is often untreated but this may create severe problems. To obtain an objective guideline for treatment of such cases, the relationship between degree of mesial inclination and developmental phase of first molar was analyzed.

Study Design: Ten boys and six girls who exhibited vertical malposition of the second primary molar were analyzed. At their first visit oral checklists and panoramic radiographs were obtained.

Place and Duration of Study: Department of Human Development & Fostering, Division of Pediatric Dentistry, School of Dentistry, Meikai University.

Methodology: Oral checklists were used at their first visit and panoramic radiographs were taken by Veraview Epocs X-550 (Morita/Kyoto). The radiographs were output as films by DRY PIX7000 (Fujifilm Medical/Tokyo). Examinations were conducted on the degree of development of the second bicuspid germ affected by a submerged second deciduous tooth, the presence of malposition, the degree of development of first molar and presence of tooth root resorption in the second primary molar, based on the panoramic radiographs.

Results: A significant positive correlation occurred between (i) second primary molar space  and degree of formation of the first molar (p<0.01); (ii) the angle between tooth axes of the first primary molar and first molar and amount of formation of the first molar (p<0.05); The vertical positional relationship between the second primary molar and the second bicuspid germ Proximity values showed larger values on the affected side; Retarded formation by 54% was recognized in the formation of the second bicuspid.

Conclusion: The prognosis for treatment success may depend on the degree of first molar formation.

Open Access Original Research Article

Morphological Pattern of Gestational Trophoblastic Disease in the University of Benin Teaching Hospital, Benin City: A Twenty Year Review (1993 – 2012)

Ikponmwosa Obahiagbon, Ezekiel E. Ugiagbe

Journal of Advances in Medicine and Medical Research, Page 1-7
DOI: 10.9734/BJMMR/2017/29417

Background: Gestational trophoblastic disease (GTD) is a spectrum of proliferative disorders of the placental trophoblast with a range of histological appearance and clinical behaviour. Although its aetiopathogenesis is as yet incompletely understood, it is well established that early detection and prompt treatment lead to the preservation of normal health and fertility.

Aim and Objectives: This study sought to determine the morphological pattern as well as the age and site distribution of the various forms of GTD histologically diagnosed in the University of Benin Teaching Hospital, Benin City, between January 1993 and December 2012. It is a hospital based, retrospective review utilizing materials from the archives of the Department of Morbid Anatomy, University of Benin Teaching Hospital.

Results: A total of 168 cases of GTD were encountered, and 103 (61.3%) of these were seen in the latter 10 years, reflecting a rise in incidence in recent years. The age range was 15 – 62 years, and the mean age was 31.27 ± 7.36 years. GTD was found to be less common at the extremes of reproductive age, with the peak prevalence being in the third and fourth decades. Partial mole was commonest (52.4%), followed by complete mole (25.0%) and choriocarcinoma (19.0%). The ratio of the benign to malignant lesions was 4:1. The uterus was the commonest site of GTD accounting for 83.3% of cases, while 16.6% of cases were distributed among ectopic sites. There was failure to clinically or grossly identify molar vesicles in 80.6% of cases of hydatidiform mole; this highlights the relevance of histopathological examination of products of conception of both intrauterine and ectopic gestation.

Conclusion: The prevalence of GTD appears to have been rising in this environment in the recent years.

Open Access Original Research Article

Prevalence of AmpC Beta-lactamase in Gram Negative Bacilli by Different Phenotypic Methods in a Tertiary Care Institute in Kashmir

Roohi Shagufta, Bashir A. Fomda, Bashir Gulnaz, Samad Lubna, Abiroo Jan, Suhail Mohd, Ahmad Junaid

Journal of Advances in Medicine and Medical Research, Page 1-9
DOI: 10.9734/BJMMR/2017/30462

Context: AmpC type cephalosporinases are Ambler class C β-lactamases. They hydrolyze penicillins, cephalosporins; except the fourth-generation compounds and monobactams. To the best of our knowledge prevalence of AmpC in our hospital is not known.   

Aims: With this background the study was undertaken to detect the prevalence of AmpC lactamases in gram-negative bacilli at our institute. We also performed four different tests, i.e. AmpC disc test, modified Hodge test, modified three dimensional spot inoculation test on a single agar plate (three in one) and inhibitor based test using boronic acid for detecting AmpC production.

Methods and Materials: Screening for AmpC was done by using cefoxitin discs. Organisms resistant to cefoxitin were tested for presence of AmpC by AmpC disc test, Modified Hodge test, Three dimensional spot inoculation test and Boronic acid disc test.

Statistical Analysis: Statistical analysis was done by Chi Square test and Fishers Exact Test with the SPSS statistical programme (version 20.0).    

Results: A total of 1323 non duplicate Gram negative bacilli were isolated during a period of one year in the Department of microbiology SKIMS. Out of these 1323 isolates, 150 isolates were found to be resistant to cefoxitin and one or more third generation cephalosporin antibiotics or showed antagonism between cefoxitin and cefotaxim discs thus fulfilling the criteria and were included in the present study. Forty five (3.4%) were positive for AmpC beta lactamases. Boronic acid test detected 38 (25.3%), AmpC disc test 35 (23.3%), MHT 29 (19.3%) and MTDST detected 27 (18%).

Conclusions: Inhibitor based test using boronic acid detected the maximum number of AmpC producing organisms. It is a simple and cost effective test that can be incorporated in routine susceptibility testing plate thus saving time also.

Open Access Original Research Article

Role of Vitamin D Deficiency in Coronary Artery Disease and Cardiac Dysfunction

Mohamed Arab, Mohamed Abdou, Medhat Ibrahim Mahmoud, Amany Mohyeldin Sediq

Journal of Advances in Medicine and Medical Research, Page 1-10
DOI: 10.9734/BJMMR/2017/29560

Introduction: Vitamin D (VD) deficiency may be an important neglected factor in the pathogenesis of cardiovascular disease and its risk factors.

Aim: Investigate the relation between VD level and both exercise parameters and left ventricular systolic and diastolic functions.

Methods: Fasting blood samples were collected from 70 patients with chest pain, and serum levels of vitamin D, glucose, and lipids were measured. They were divided into 2 groups according to VD level. All patients were scheduled for exercise treadmill test and echocardiography.

Results: 30 patients had normal serum VD. They had lower incidence of diabetes, lower levels of total cholesterol and S.LDL. Also, they had longer exercise time (0.37±0.05 vs. 0.31±0.06, P 0.002) with higher metabolic equivalents (METs) (9.52±1.33 vs. 8.49±1.45, P 0.003) and minimal ST-segment depression (0.61±0.11 mm vs. 2.41±1.08 mm, P <0.001). No difference between both groups regarding ejection fraction (P> 0.05) but there was a significant decrease in the E/A ratio of the mitral valve in patients with low VD (1.26±0.27 vs.1.01±0.31, P 0.001). Patients with normal exercise test were 35 patients (50%). They had higher VD level (57.60±9.29 nmol/l vs 34.44±8.11, P <0.001). There was a significant negative correlation between VD and total cholesterol, S.LDL, and the degree of ST-segment depression in exercise ECG. A significant positive correlation was found between VD and both METS and E/A ratio of the mitral valve. Using logistic regression analysis, VD, METs, and diabetes were predictors for both CAD and cardiac dysfunction. Serum VD less than ≤47 nmol/l can predict coronary artery disease (CAD) and cardiac dysfunction with high accuracy (94.4% and 71.4% respectively).

Conclusion: A strong correlation exists between vitamin D and some of CAD risk factors and reduced vitamin D could have a role in exercise parameters abnormalities developed during stress test and diastolic dysfunction seen in patients presented with chest pain.