Health And Clinical Research

Congenital Anomalies (CA) in Latin America are responsible for more than 20% of deaths that occur in the period of 0- 4 years of life, and may result in long-term disability, which may lead to negative emotional, individual, familiar, social and economic impact. In particular Cleft Lip and Palate are among the most
common CA and individuals with this condition may encounter problems in areas, such as feeding, speech, hearing and social integration, which can be treated with a multi-disciplinary team. The aim of this report was to present the case study proposal of a cognitive-behavioral intervention with support of positive psychology strategies for an 11 years old boy, with a cleft lip and palate. The boy was evaluated with ahealth behavioral interview, self-report, and functional behavioral analysis for the case formulation (Clinical Pathogenesis Map, Clinical Strengths Map and Goal Attainment Map). He participated in 20 sessions based in the “Optimistic Game”. The results had shown clinical changes in the emotional regulation, attributional style (pessimistic vs optimistic) and behavioral goals (social skills, health behaviors). These improvements allowed the expression of Positive emotions, Engagement, positive Relationships, Meaning and Accomplishment that are the components of the PERMA model in Positive Psychology.
Key words: orofacial clefts, attributional style, well-being, PERMA model.

The clinical research sector is a booming industry not only in India but around the globe as well. A wide range of clinical trials are being conducted due to the elderly population, prevalence of illnesses such as diabetes and cancer and new developments in research

Background Patient satisfaction is considered as one of the desired outcomes of health care and it is directly related with utilization of health services. The most important predictor of patients' overall satisfaction with hospital care is particularly related to their satisfaction with nursing care. However, there is dearth of published studies in the area. The aim of this study is to assess the level and factors that determines adult inpatient satisfaction towards nursing care at Felegehiwot Referral Hospital. Methods A facility based cross-sectional study was conducted from January 1-30, 2015. A sample size of 244 inpatients was determined using single population proportion formula including 10% non-response rate. Simple random sampling method was used to select participants. Interviewer administered questionnaire was employed to collect data using the adapted Newcastle Satisfaction Scale with nursing services. Data was analyzed using SPSS version 16. Both bivariate and multivariate analysis was conducted to determine the effect of independent variables on inpatients' satisfaction with nursing care at 0.05 level of significance. Result A total 236 inpatients participated in the study yielding a response rate of 96.9%. Participants who were farmers, rural residents, and female took the greater percentage. The overall level of satisfaction was 44.9%. Sex and occupation, were the only predictors of patient level of satisfaction with nursing care. Among satisfaction items, the amount, nurses know your care (78%), the nurse's helpfulness (55%), and nurses' treatment of patients as an individual (54%) were the three top scores respectively. whereas nurses response to patients request (42.6%), the amount and type of information nurses gave to patients about their condition and treatment (43.2%), and the way nurses explain things to patients (43.4%) had the least scores. Conclusion The level of inpatient satisfaction with nursing care was low. Inpatients were less informed about their disease condition, treatment, and prognosis by nurses since it is essential for making decision related with their care. The hospitals should consider mechanisms to improve the nurses' way of communication and interpersonal relationships beyond training on direct patient care.

Asthma is a disease characterized by wide variations in
pathogenesis that cause resistance to flow in intrapulmonary
airways. The dramatic changes in the architecture of the airway
walls are usually connected to allergic reaction or other forms of
hyper sensitivity, causing marked spasms that lead to difficulty in
breathing. It is possible to relieve or remove the symptoms in the
majority of patients by adopting the clinical guidelines for
pharmacotherapy of asthma which include inhaled corticosteroids,
long and short acting beta agonists, muscarinic antagonists,
leukotriene modifiers, xanthine drugs and some allergy medicines.
The proper use of these agents can aid in reducing or reversing
many symptoms of asthma. Certain methods of using medicines,
for example the correct use of the inhaler for relief and
maintenance therapy, are also associated with a significant
reduction in symptoms. This can be achieved by a pharmacist’s
intervention that can provide a detailed understanding of the
current rational drug choices and proper medication use to the
patient. Nowadays massive resources are being ploughed into
research in a concerted effort to halt the progress of this illness
that can strike in all ages.

Review Soft tissue changes following extraction vs. nonextraction orthodontic fixed appliance treatment: a systematic review and meta-analysis Konstantonis D, Vasileiou D, Papageorgiou SN, Eliades T. Soft tissue changes following extraction vs. nonextraction orthodontic fixed appliance treatment: a systematic review and meta-analysis. Eur J Oral Sci 2018; 00: 1–13. © 2018 Eur J Oral Sci The aim of this systematic review was to assess the effect of systematic extraction protocols during orthodontic fixed appliance treatment on the soft tissue profile of human patients. Nine databases were searched until December 2016 for controlled clinical studies including premolar extraction or nonextraction treatment. After elimination of duplicate studies, data extraction, and risk-of-bias assessment according to the Cochrane guidelines, random-effects meta-analyses of mean differences (MD) or standardized mean differences (SMD) and their 95% CIs were performed, followed by subgroup, meta-regression, and sensitivity analyses. Extraction treatment was associated with increased lower lip retraction (24 studies; 1,456 patients; MD = 1.96 mm), upper lip retraction (21 studies; 1,149 patients; MD = 1.26 mm), nasolabial angle (21 studies; 1,089 patients; MD = 4.21°), soft-tissue profile convex-ity (six studies; 408 patients; MD = 1.24°), and profile pleasantness (three studies; 249 patients; SMD = 0.41). Patient age, extraction protocol, and amount of upper incisor retraction during treatment were significantly associated with the observed extraction effects, while the quality of evidence was very low in all cases due to risk of bias, baseline confounding, inconsistency, and imprecision. Although tooth extractions seem to affect patient profile, existing studies are heterogenous and no consistent predictions of profile response can be made.

Se desarrolló una estrategia cognitivo‐conductual para el manejo del duelo en la diada madre‐hijo. Participaron una mujer de 40 años y su primogénito (e hijo único) varón de 9 años. El motivo de consulta de la madre fueron síntomas de depresión y ansiedad ante la posible muerte del esposo (enfermo crónico degenerativo por ingesta de alcohol). Se realizó entrevista para identificar el desarrollo del problema, la definición del mismo, así como las variables distantes, antecedentes, organísmicas y de respuesta y si hubo intentos anteriores para solucionarlo. Se desarrolló un Mapa Clínico de Patogénesis (MCP) para la madre y otro para el niño, lo
que permitió la elaboración del Mapa de Alcance de Metas (MAM) compuesto por las estrategias potenciales de intervención, las variables de resultados instrumentales, y las metas de resultados finales. Ambos pacientes alcanzaron los objetivos terapéuticos, reportaron significancia clínica y satisfacción con el tratamiento.

Vitiligo is a common autoimmune pigmentary disorder of great socio-medical importance. It is characterized by white spots appeared on the skin due to melanocytes deficiency. It can be correlated with Shvitra in Ayurveda. Due to side effects and limitation of the contemporary science, some harmless and effective medicines are expected from Alternative medical sciences. Ayurveda has great potential to treat such autoimmune skin diseases. Here a case of chronic vitiligo treated with Ayurvedic management is recorded.

Tissue engineering is a newly emerging biomedical technology, which aids and increases the repair and regeneration of deficient and injured tissues. It employs the principles from the fields of materials science, cell biology, transplantation, and engineering in an effort to treat or replace damaged tissues. Tissue engineering and development of complex tissues or organs, such as heart, muscle, kidney, liver, and lung, are still a distant milestone in twenty-first century. Generally, there are four main challenges in tissue engineering which need optimization. These include biomaterials, cell sources, vascularization of engineered tissues, and design of drug delivery systems. Biomaterials and cell sources should be specific for the engineering of each tissue or organ. On the other hand, angiogenesis is required not only for the treatment of a variety of ischemic conditions, but it is also a critical component of virtually all tissue-engineering strategies. Therefore, controlling the dose, location, and duration of releasing angiogenic factors via polymeric delivery systems, in order to ultimately better mimic the stem cell niche through scaffolds, will dictate the utility of a variety of biomaterials in tissue regeneration. This review focuses on the use of polymeric vehicles that are made of synthetic and/or natural biomaterials as scaffolds for three-dimensional cell cultures and for locally delivering the inductive growth factors in various formats to provide a method of controlled, localized delivery for the desired time frame and for vascularized tissue-engineering therapies.

Acute coronary syndromes (ACS) represent a range of ischemic heart disease from unstable angina to myocardial infarction (MI) and may involve large areas of cardiac necrosis. The symptomatic manifestations of an acute MI (AMI) may be varied and ECG is also non-diagnostic in about 50% of cases, which poses a risk for potential misdiagnosis. Biochemical markers and cardiac enzymes like transaminases and creatine kinase (CK) were used early as diagnostic markers, and gradually improved markers like creatine ...

Background: A Dyop (or dynamic optotype) is a spinning visual target which uses the strobic detection of the spinning gaps/segments of the ring to measure visual acuity. Methods: Forty subjects with visual acuity better than 6/12 (20/40) and ages between 20 and 28 years (24.48 ± 2.01 years) were recruited at the University of Benin Optometry Clinic. Snellen and Dyop acuity charts were displayed on a monitor at a distance of 6 meters. The assessment sequence between the two acuity chart formats was alternated for every other patient to reduce potential refractionist bias. Subjective refraction was measured in both eyes, and the duration of testing for each patient and each method was recorded. Results: There was no significant mean Thibos notations difference, M (p = 0.77), J0 (p = 0.27), and J45 (p = 0.57) using the Bland-Altman plot and 95% limits of agreement between the two charts, and there were no differences as to age or gender. There was, however, a disparity in the mean acuity of about 0.25 diopters with the mean Snellen acuity of 1.60 ± 0.21 decimal units and the mean Dyop acuity of 1.17 ± 0.14 decimal units with a linear relationship: y = 0.3121x + 0.6709 (p = 0.00). The refraction with a Dyop acuity chart also typically took half as long (339 ± 122 seconds) as the refraction with a Snellen acuity chart (680 ± 281 seconds), p = 0.00.

"The clinical bacteria of multi-drug resistant to some antibiotics are
considered a common problem in the world wide. Alternative
antibacterial strategies are urgently needed, and thus this situation
has led to a re-evaluation of the therapeutic use of ancient
remedies, such as plants and plant-based products, including
Nigella sativa (N. sativa). This study aimed to evaluate the
antibacterial activity of Yemeni N. sativa oil against some Clinical
Bacterial Isolates (CBI) and Control Strains of Bacteria (CSB) in
comparison with Augmentin® (Amoxicillin and Clavulanic Acid).
This study was carried out in Sana’a city during the period of one
year from May 2012 to April 2013. The antibacterial activity of oil
with different concentrations was determined by using disc agar
diffusion technique against CBI (Staphylococcus aureus and
Pseudomonas aeruginosa) and CSB (Staphylococcus aureus
ATCC25619, Pseudomonas aeruginosa ATCC29737), also the
Minimum Inhibition Concentration (MIC) of oil extract was
determined. The results indicated that, the highest significant
antibacterial activity was at the maximum concentration of the oil
against Staphylococcus aureus and Pseudomonas aeruginosa in
comparison with Augmentin ® discs (p < 0.05) respectively. This
study observed that, there was strong positive correlation between
the diameter zone (DZ-mm) and oil concentrations (%). In
addition, the DZ (mm) of the oil for CSB was higher than CBI.
Also the oil activity was found to be more effective against
Staphylococcus aureus than Pseudomonas aeruginosa. On the
other hand, the MIC of the oil against CBI were ranged between ≥
0.5% and 4%. Whereas, the CSB particularly Staphylococcus
aureus were sensitive to low concentrations of oil. It could be
concluded that, the oil had high antibacterial effect against CSB
and CBI with high concentration and more effective than
Augmentin® discs."

Fasting helps the vital energy to remove the toxic matter from the blood and purify the system. Fasting awakens the mind and enhances inner tranquility many people are living a very unhealthy, sedentary lifestyle where no such physical activities are involved. Sedentary lifestyle and meals three times per day (breakfast, lunch, dinner and snacks in between) often leads to metabolic morbidities that lead to many diseases that they are unaware of. In these situations, the concept of Intermittent Fasting gained much popularity globally. Intermittent fasting (IF) is basically a banqueting mosaic and not a diet, one has to follow. IF in general is a regimen where one can refrain themselves from eating for some fixed consecutive hours mainly more than 12 hours fasting and rest is eating time period. The objective of this review paper is to summarize and bring out the fruitful wellness benefits of Intermittent Fasting that have shown clinical results from human studies as well as from animal studies. IF can counteract many diseases and functional improvement was shown in various experimental models with a wide range of diseases and disorders. IF can be paradigmatic in developing new approach to weight loss, reduction in inflammation, deduction and prevention in skin disease, decrease in Hypertension, metabolic switching, diabetes prevention and maintenance, maintaining insulin level and increase insulin sensitivity, prevention and help in cardiovascular disease and stroke, increase in wound healing process, boosting immune system, promoting autophagy, help in treating neurodegenerative disease like Alzheimer disease and Vascular Dementia and Seizures.

Patient satisfaction has been increasingly recognized as an important outcome for the health care delivery system and is increasingly studied in developing countries. Many women report lower levels of satisfaction with care and support they receive during the postnatal period than any other phase of their maternity care. The objectives of the study were; determining the level of women's satisfaction with postnatal care, determining the influence of socio-demographic characteristics on satisfaction with postnatal care. Descriptive cross-sectional research design was used. The study population was postpartum women aged 15-49 years who had delivered in Embu hospital. The study employed systematic random sampling method to come up with a sample size of 205 respondents. A structured client exit questionnaire, focused group discussions and key informant interviews were used to collect data. Data was analyzed using SPSS version 20 and presented in percentages, frequencies and cross tabulations. The study findings revealed that majority of the women 54.6% were satisfied with postnatal care services provided. Findings from this study also showed that socio-demographic variables like age, marital status, education level, occupation and monthly income did not have a significant relationship with women's satisfaction with postnatal care. The study concluded that there is still a percentage of women 45.4% who were still dissatisfied with the postnatal care services provided. The study recommended that the county government together with the hospital administration should help in installation of Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) to help seek feedback from customers hence improve the satisfaction level of clients. The study also recommended that the same study should be done in other hospitals within the Sub Counties and in the rest of 47 Counties to enable generalization of results.

Acute coronary syndromes (ACS) represent a range of ischemic heart disease from unstable angina to myocardial infarction (MI) and may involve large areas of cardiac necrosis. The symptomatic manifestations of an acute MI (AMI) may be varied and ECG is also non-diagnostic in about 50% of cases, which poses a risk for potential misdiagnosis. Biochemical markers and cardiac enzymes like transaminases and creatine kinase (CK) were used early as diagnostic markers, and gradually improved markers like creatine kinase MB (CK-MB) evolved and are used to diagnose AMI and assess cardiac damage. But their non-specificity has been an issue and has led to introduction of more specific and sensitive cardiac biomarkers, e.g troponins. Troponins are quite efficacious and better than earlier markers, and they not only diagnose, but also help in risk assessment and therapeutic decision-making. However, the search for an ideal cardiac marker is still on, though troponins seem to have lot of qualities ...

The goal of this project is to develop and utilize a microfluidic device to isolate and enrich tumor cells circulating in peripheral blood. Circulating tumor cells (CTCs) have been used as biomarkers for cancer diagnostics and prognosis. However, the rarity of these cells (roughly 1 in a billion) poses a technological challenge to sort and concentrate them. CTCs hold potential sources for early detection, characterization, monitoring of cancers, and development of personalized treatment. The project is currently funded by the US National Cancer Institute (NCI) of the National Institutes of Health (NIH).

Outcomes assessment for intervention studies requires blinding of reviewers to prevent bias. We used Mozilla Firefox and the Greasemonkey Add-on to remove notes generated for intervention patients during a randomized controlled trial to ensure blinding during electronic chart review. Similar methods could be employed with other web-based electronic medical records.

Background: To achieve effective antiretroviral therapy (ART) outcomes, adherence to an antiretroviral regimen and a good immunometabolic response are essential. Food insecurity can act as a real barrier to adherence to both of these factors. Many people living with human immunodeficiency virus (PLHIV) treated with ART in the Democratic Republic of the Congo (DRC) are faced with nutritional challenges. A significant proportion are affected by under nutrition, which frequently leads to therapeutic failure. Some HIV care facilities recommend supplementation with Moringa oleifera (M.O.) Lam. leaf powder to combat marginal and major nutritional deficiencies. This study aims to assess the impact of M.O. Lam. leaf powder supplementation compared to nutritional counseling on the nutritional and immune status of PLHIV treated with ART. Methods: A single-blind randomized control trial was carried out from May to September 2013 at an outpatient clinic for HIV-infected patients in Kinshasa (DRC). Sixty adult patients who were at stable HIV/AIDS clinical staging 2, 3 or 4 according to the World Health Organization (WHO), and were undergoing ART were recruited. After random allocation, 30 patients in the Moringa intervention group (MG) received the M.O. Lam. leaf powder daily over 6 months, and 30 in the control group (CG) received nutritional counseling over the same period. Changes in the body mass index (BMI) were measured monthly and biological parameters were measured upon admission and at the end of the study for the patients in both groups.

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89·6 per cent) compared with that in countries with a middle...

“KALLADAIPPU” (Urolithiasis) “KALPIRAMIYAM”(Urolithiasis) are the synonyms in Siddha and the term equated to renal calculi in allopathic system of medicines. An increasing affluence and adaptation of Western diet habits in many developing countries seem likely to contribute to the changes for the development of renal calculi. Siddha medicine describes certain formulations as Lithotriptic and diuretic which is used in the treatment of renal calculi successfully. This case reported again is an example that proves the efficacy of Siddha medicines for expulsion of renal stones. The synergistic action enhanced resulting in disintegration and elimination of urinary stones from urinary tract.

Nowadays, the need to use natural products became of great importance, as because resistance of microorganisms to antibiotics is increase day by day and also to decrease the side effects on human beings. A wide range of medicinal plant parts are used to treat numbers of diseases from ancient time. Traditionally Cynodon dactylon is used in skin trouble, treatment of wounds, as laxative, brain and heart tonic, emetic, expectorant, carminative, and for pains, inflammations and toothache etc. Brassica rapa M27 seed is used as rubefacient and a very good folk remedy for cancer. This work was done to investigate the phytochemical properties and the antioxidant activity of methanolic extracts of whole plant of Cynodon dactylon and seed of Brassica rapa M27. In this study free radical scavenging activity was determined by in-vitro assay models such as DPPH free radical, reducing ability. Quercetin was used as reference standard. The findings indicated that it contains different phytochemical constituents and promising antioxidant activity of crude extracts of the above mentioned plants in a dose dependent manner and needs further exploration for their effective use in both modern and traditional system of medicine which can be used to treat different types of diseases.

""Introduction: Research has shown that single-item tools, like the Distress Thermometer (DT), are comparable to longer ones, like the Hospital Anxiety and Depression Scale (HADS). In this study, we tested the validity of the DT in a population of Singapore cancer outpatients, and determined the cutoff  scores on the DT for clinically relevant distress and impaired quality of life (QOL). We also documented the prevalence of anxiety, depression, and QOL impairments in this population.
Methods: One hundred and five patients (Mdn age = 51-60 years, 64% female, and 71% Chinese) diagnosed with various cancers participated in this study. They completed a standard sociodemographic form, the DT and the Problem List, the HADS, and the EuroQOL Quality of Life Scale (EQ-5D).
Results: Almost a third of patients had clinically significant emotional distress, with 15-16% having probable levels of anxiety and depression. Almost half (41-55%) had an impaired QOL compared to Singapore population norms. Receiver operating characteristic curve analyses identified an area under the curve of 0.89 (SE = 0.36, 95% CI [0.82, 0.96], p < .001) when compared to the HADS cut-off score of 15. A cut-off score of 5 on the DT had the best sensitivity (0.88) and specificity (0.81). Participants above the DT cut-off score of 5 reported significantly more emotional  problems (worry, nervousness, depression, sadness), insurance/finance-related problems, and sleep problems. They also scoredsignificantly lower on EQ-5D, with more QOL impairments in the domains of carrying out their usual
activities and anxiety/depression.
Conclusion: Levels of distress, anxiety, depression, and QOL impairments are high in this population. The DT was found to be a valid tool for distress screening in the Singapore cancer population, with a recommended cut-off score of 5.""

Objectives: The aim of the present study was to compare and correlate body composition measurements and bone mineral density in patients with rheumatoid arthritis (RA) and age-matched controls to identify the possible prediction factors for low bone mass, fractures, and body composition changes.
Methods: Ninety-two RA patients and 92 age- and sex-matched healthy controls were included for the study. A health assessment questionnaire (HAQ) score, disease activity score - (DAS 28), forearm bone mineral density (BMD) determined by dual energy x-ray absorptiometry (DXA), estimated heel BMD based on quantitative ultrasound and  body composition parameters were analyzed in  both RA patients and controls.
Results: Body fat mass (BFM) differed significantly between RA patient group (26.37±10.05 (kg)) and controls (30.11±8.64 kg, p<0.05). The Fat free mass (FFM) was also significantly different between RA patients (37.63±9.82 kg) and controls (42.97±6.68 kg, p<0.01). Forearm BMD and estimated heel BMD was significantly higher in controls (0.377±0.04 g/cm2, 0.493±0.08 g/cm2), than in RA patients (0.320±0.13 g/cm2 , 0.452±0.10 g/cm2;  p<0.01 and  p<0.05, respectively). The Fat free mass (FFM), muscle mass (MM), segmental muscle mass (SMM) was significantly correlated with the estimated  heel BMD and forearm BMD.
Conclusions: These findings indicated that the body composition measurements might be useful for predicting bone mineral density (BMD) in RA patients. High RA activity was found to be  associated with reduced function, and altered body composition and BMD.

Background: A Dyop (or dynamic optotype) is a spinning visual target which uses the strobic detection of the spinning gaps/segments of the ring to measure visual acuity. Methods: Forty subjects with visual acuity better than 6/12 (20/40) and ages between 20 and 28 years (24.48 ± 2.01 years) were recruited at the University of Benin Optometry Clinic. Snellen and Dyop acuity charts were displayed on a monitor at a distance of 6 meters. The assessment sequence between the two acuity chart formats was alternated for every other patient to reduce potential refractionist bias. Subjective refraction was measured in both eyes, and the duration of testing for each patient and each method was recorded. Results: There was no significant mean Thibos notations difference, M (p = 0.77), J0 (p = 0.27), and J45 (p = 0.57) using the Bland-Altman plot and 95% limits of agreement between the two charts, and there were no differences as to age or gender. There was, however, a disparity in the mean acuity of about 0.25 diopters with the mean Snellen acuity of 1.60 ± 0.21 decimal units and the mean Dyop acuity of 1.17 ± 0.14 decimal units with a linear relationship: y = 0.3121x + 0.6709 (p = 0.00). The refraction with a Dyop acuity chart also typically took half as long (339 ± 122 seconds) as the refraction with a Snellen acuity chart (680 ± 281 seconds), p = 0.00.

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89·6 per cent) compared with that in countries with a middle...

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89·6 per cent) compared with that in countries with a middle...

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89·6 per cent) compared with that in countries with a middle...

Puberty is a slow process involving several years during which the physical growth and secondary sexual characters develop to maturity and the menstruation is established. The menarche, or time onset of menstruation, varies with race and family, but the average for most
Girls is from 12 to 13 years of age. The early puberty seen in developed countries is due to improved nutritional status. During childhood, before the onset of puberty, oestrogen secretion is too small to cause development of the reproductive organs. At puberty the hypothalamus awakes and excites the pituitary to secrete gonadotrophins; these in turn stimulates the ovary to discharge ova and to secrete its hormones. Thus puberty begins at 10-14 years and is regarded as ending with the first menstrual period usually at 13- 15 years, the range being 10-15 years. At whatever age the menarche appears it is usually some years before regular, adult ovulatory menstrual cycles are established.