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A 9 mm Occlutech septal occluder Flex II device was retrieved in a 4-year-old 22 kg child; A 6 Fr Cook® Flexor sheath (child) was inserted into a 9 Fr Occlutech® ASD Delivery Set (mother). Once the tip of the smaller sheath was close to the device, a 4 Fr right Judkins catheter was introduced with a snare. The right atrial hub was captured and withdrawn to the level of the 6 Fr sheath which was then withdrawn into the 9 Fr sheath before being removed completely. The “mother and child” technique offers a greater likelihood of slenderising and retrieving embolised devices.
In Iraq, where Islamic State of Iraq and Syria (ISIS) and other groups have contributed to escalating violence in recent years, understanding the epidemiology of intentional firearm-related fatalities is essential for public health action.
The Iraqi Ministry of Health (MoH; Baghdad, Iraq) compiles surveillance of fatal injuries in eight of Iraq’s 18 governorates (Baghdad, Al-Anbar, Basrah, Erbil, Kerbala, Maysan, Ninevah, and Al-Sulaimaniya). Information is collected from coroner’s reports and interviews with family members. Analysis was performed on intentional firearm-related injuries, excluding injuries from intentional self-harm or negligent discharges, that occurred during 2010-2013, a subset of all fatal injuries, and compared to previously published explosive-related fatalities.
Overall, the dataset included 7,985 firearm-related fatalities. Yearly fatalities were: 2010=1,706; 2011=1,642; 2012=1,662; and 2013=2,975. Among fatalities, 86.0% were men and 13.7% women; 83.4% were adults and 6.2% children <18 years of age. Where age and sex were both known, men aged 20-39 years accounted for 56.3% of fatalities. Three “high-burden” governorates had the highest fatality rate per 100,000 population—Baghdad (12.9), Ninevah (17.0), and Al-Anbar (14.6)—accounting for 85.9% of fatalities recorded in the eight governorates. Most fatalities occurred in the street (56.3%), followed by workplace (12.2%), home (11.3%), and farm/countryside (8.4%). Comparing the ratio of firearm-related fatalities to explosives-related fatalities revealed an overall ratio of 2.8:1. The ratio in Baghdad more than doubled from 2.9 in 2010 to 6.1 in 2013; the highest ratios were seen outside the high-burden governorates.
Firearm-related fatalities remained relatively stable throughout 2010-2012, and almost doubled in 2013, correlating with increased ISIS activity. Three governorates contributed the majority of fatalities and experienced the highest fatality rates; these saw high levels of conflict. Firearm-related fatalities disproportionately affected younger men, who historically are over-represented as victims and perpetrators of violence. More than one-half of fatalities occurred in the street, indicating this as a common environment for conflict involving firearms. Firearms appear to account for more fatalities in Iraq than explosives and largely accounted for escalating violence in Baghdad during the study period. The high ratio observed outside the high-burden governorates is reflective of very low numbers of explosives-related fatalities; thus, violence in these governorates is likely non-conflict-related. These observations provide valuable public health information for targeted intervention to prevent violence.
NerlanderMP, LeidmanE, HassanA, SultanASS, HussainSJ, BrowneLB, BilukhaOO. Fatalities from Firearm-Related Injuries in Selected Governorates of Iraq, 2010-2013. Prehosp Disaster Med. 2017;32(5):548–555.
The aim of this study was to describe the most recent trends and epidemiologic patterns of fatal injuries resulting from explosions in Iraq, one of the countries most affected by violence from explosive devices.
Iraqi Ministry of Health (MoH) routine prospective injury surveillance collects information on all fatal injuries recorded by coroners from physical examinations, police reports, and family members in eight governorates of Iraq: Baghdad, Al-Anbar, Basrah, Erbil, Kerbala, Maysan, Ninevah, and Al-Sulaimaniya. This study analyzed explosive-related fatal injuries that occurred from January 1, 2010 through December 31, 2013.
Analysis included 2,803 fatal injuries. The number of fatal injuries declined from 2010 through 2012, followed by an increase in 2013. One-thousand one-hundred and one explosion-related fatalities were documented in 2013, more than twice as many as in 2012 or in 2011. Most fatalities were among men aged 20-39 years. Of all causalities, 194 (6.9%) were among females and 302 (10.8%) were among children aged less than 18 years. The majority of fatalities were caused by improvised explosive devices (IEDs): car bombs (15.3%), suicide bombs (4.0%), and other IEDs (29.6%). The highest number of fatalities occurred in streets and roads. Of all deaths, 95.6% occurred in three governorates: Baghdad, Ninevah, and Al-Anbar.
Explosives continue to result in a high number of fatal injuries in Iraq. Following a period of declining violence from explosives, in 2013, fatalities increased. Most explosion-related injuries resulted from IEDs; males aged 20-39 years were at greatest risk.
BilukhaOO, LeidmanEZ, SultanASS, HussainSJ. Deaths due to Intentional Explosions in Selected Governorates of Iraq from 2010 to 2013: Prospective Surveillance. Prehosp Disaster Med. 2015;30(6):586–592.
The present study determined trends in malnutrition among under-5 children in urban and rural areas of Bangladesh.
The study was conducted in the urban Dhaka and the rural Matlab hospitals of the International Centre for Diarrhoeal Disease Research, Bangladesh, where every fiftieth patient and all patients coming from the Health and Demographic Surveillance System were enrolled.
A total of 28 816 under-5 children were enrolled at Dhaka from 1993 to 2012 and 11 533 at Matlab between 2000 and 2012.
In Dhaka, 46 % of the children were underweight, 39 % were stunted and 28 % were wasted. In Matlab, the corresponding figures were 39 %, 31 % and 26 %, respectively. At Dhaka, 0·5 % of the children were overweight and obese when assessed by weight-for-age Z-score >+2·00, 1·4 % by BMI-for-age Z-score >+2·00 and 1·4 % by weight-for-height Z-score >+2·00; in Matlab the corresponding figures were 0·5 %, 1·4 % and 1·4 %, respectively. In Dhaka, the proportion of underweight, stunting and wasting decreased from 59 % to 28 % (a 53 % reduction), from 54 % to 22 % (59 % reduction) and from 33 % to 21 % (36 % reduction), respectively, between 1993 and 2012. In Matlab, these indicators decreased from 51 % to 27 % (a 47 % reduction), from 36 % to 25 % (31 % reduction) and from 34 % to 14 % (59 % reduction), respectively, from 2000 to 2012. On the other hand, the proportion of overweight (as assessed by BMI-for-age Z-score) increased significantly over the study period in both Dhaka (from 0·6 % to 2·6 %) and Matlab (from 0·8 % to 2·2 %).
The proportion of malnourished under-5 children has decreased gradually in both urban and rural Bangladesh; however, the reduction rates are not in line with meeting Millennium Development Goal 1. Trends for increasing childhood obesity have been noted during the study period as well.
To evaluate the referral patterns of patients to a stroke prevention clinic (SPC) and to test the adequacy of pre-referral diagnosis and management of modifiable risk factors for stroke.
We collected prospective data on consecutive patients referred to the SPC at University of Alberta Hospital in Edmonton, Alberta, Canada. Outcome measures included: alternate diagnoses to stroke or transient ischemic attack (TIA), uncontrolled or undiagnosed hypertension, hyperlipidemia and diabetes, therapies, and investigations leading to carotid endarterectomy.
Two thousand and eleven patients were referred to SPC. Nearly 25% of the referrals originated from the emergency room and the rest from general physicians. Of the referrals, 68.7% were confirmed as TIA or stroke at the SPC. Among 1381 patients with TIA or stroke, 736 had history of hypertension. Uncontrolled hypertension was found in 265 patients (36.0% of those with hypertension: 95% CI: 32.5–39.5) while undiagnosed hypertension was found in 103 (15.9% of those without hypertension: 95%CI: 13.14-18.79). History of hyperlipidemia was present in 451 patients (32.6%) and 356 (78.9%: 95% CI: 75.2-82.69) of these patients were not at target for secondary prevention. Among 930 patients without history of hyperlipidemia, 739 (79.5%: 95% CI: 76.8-82.1) were diagnosed with hyperlipidemia through the SPC. Fasting blood glucose levels above 7.1 mmol/L in patients with and without history of diabetes were 221 (79.2%: 95% CI: 74.5-83.9) and 66 (6%: 95%CI: 4.6-7.4) respectively.
Management of risk factors for stroke needs improvement. SPCs should consider actively managing the classical modifiable risk factors of stroke.
Doppler ultrasound (DUS) is used as a screening tool to assess internal carotid artery (ICA) disease. Recent reports suggest that the DUS may be inaccurate in over 28% of patients. We sought to evaluate the accuracy of DUS, when performed in a dedicated stroke prevention clinic (SPC).
We retrospectively reviewed the charts of patients who had a DUS performed in our SPC, followed by conventional cerebral angiography. Three groups of patients were defined. Group 1 had DUS measured ICA stenosis of >50%; Group II had a DUS measured ICA stenosis of <50%; Group III had complete ICA occlusion on DUS.
Sixty-seven patients (69 arteries) were included in the study. There were 45 patients in Group I and based on the findings of cerebral angiography, carotid endarterectomy was considered inappropriate in only one patient. - a misclassification rate of 2.2% (95%CI: 0 – 6.5%). Group II consisted of 19 patients and on cerebral angiography, none of these patients had a stenosis of >50% - a misclassification rate of 0%. Group III consisted of five patients in whom DUS showed complete ICA occlusion. The angiogram confirmed the occlusion in all five patients – a misclassification rate of 0%. Overall, misclassification rate was 1.45% (95% CI: 0 - 4.3%).
Doppler ultrasound when performed in a stroke prevention clinic (SPC), has a high accuracy in measuring ICA stenosis of >50%. Doppler ultrasound is reliable in detecting complete ICA occlusion and finally DUS is a reliable screening tool to rule out clinically significant ICA stenosis.
The prosobranch snail Clypeomorus bifasciata in Kuwait Bay was examined for digenean infections over a one year period during 1994/1995. A total of 1500 snails was examined and 567 (37.8%) were found to harbour nine digenean species. The prevalence of a microphallid species was 33.9% while each of the others occurred in less than 1.2% of the snails. The prevalence of infection increased with shell size. Multiple infections were observed in only five of the infected snails and the microphallid was involved in all of them. Snails were infected with the microphallid throughout the year and there appeared to be two peaks in the proportion of infected snails shedding cercariae, a winter peak from November to January and a summer peak from June to August. The crab Xantho exaratus collected from snail sampling sites was heavily parasitized by microphallid metacercariae of the genera Longiductotrema and Microphallus. This is the first report on microphallid metacercariae in crabs in the Arabian Gulf region.
The prosobranch gastropod Cerithidea cingulata (Gastropoda: Potamididae) in Kuwait Bay was examined for larval trematode infections over a 17-month period. A total of 2537 snails were examined and 1265 (49.9%) found to be infected with one or more species of trematodes. The component community in the snail comprised 12 species representing the families Cyathocotylidae (2), Echinostomatidae (2), Haplosplanchnidae (1), Heterophyidae (2), Microphallidae (1), Philophthalmidae (2), Plagiorchiidae (1) and Schistosomatidae (1). Cyathocotylid II (41.6%) was by far the most prevalent species followed by the microphallid (3.9%), the two species comprised 90% of the total trematode fauna. The prevalence of infection increased with shell size and was significantly higher in male (47%) than female (33%) snails. Multiple infections were observed in only 15 (1.2%) of the infected snails; cyathocotylid I and cyathocotylid II combination occurred 14 times and heterophyid I and the microphallid occurred once. Trematode species were more diverse and prevalent in winter, and cercarial shedding peaked in summer. Behaviour of the definitive host and snail population dynamics were probably the major contributors to the detected temporal pattern in the infections.
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