Abstract:

Objectives: To evaluate clinical, radiological and immunohistochemichal profile of non small cell lung carcinoma (NSCLC). Settings and study design: A cross sectional study conducted among all diagnosed cases of primary lung malignancy in the Department of Respiratory Medicine MES Medical College Perinthalmanna . Materials and methods: The 41 biopsy proven cases of NSCLC was studied during a period of 1 ½ years, A detailed history, clinical evaluation and the relevant investigation is done, small biopsy specimens are collected, a histopathological evaluation was done and the markers Thyroid Transcription Factor-1(TTF1), Epidermal Growth Factor Receptor (EGFR) and p-63 status was determine by immunohistochemistry(IHC) Results: Of the 41 cases, Squamous cell carcinoma was the predominant histological type with a male predominance and a peak incidence in 61-70 yrs of age. (58.53%) cases showed EGFR positivity. TTF1 positivity was predominant with adenocarcinoma and p63 positivity with squamous cell carcinoma. Smoking status and EGFR in adenocarcinoma shown that there is a significant number of EGFR positivity associated with non-smokers and all were females. The study could attain a 85.71% sensitivity and 92.59% specificity for ttf1 in adenocarcinoma and 88% sensitivity and 100% specificity for p63 in squamous cell carcinoma. Conclusion: IHC can be used as a rapid and effective tool for diagnosing the histologic type of NSCLC because of its high sensitivity and specificity. In adenocarcinoma, there is a significant number of EGFR positivity associated with non-smokers females.

References:

[1.]   American Cancer Society. Cancer Facts and Figures 2011. Available at: http://www.cancer.org/Research/CancerFactsFigures/CancerFactsFigures/cancer-facts-figures-2011

[2.]   Antonio Marchetti, Carla Martella, Lara Felicioni, Fabiobarassi, Simona Salvatore, Antonio Chella et al:EGFR Mutation In Non – Small Cell Lung Cancer: Analysis of a Large Series of Cases And Development of a Rapid and Sensitive Method for Diagnostic Screening With Potential Implication on Pharmacologic Treatment. Journal of Clinical Oncology 2005;23(4):857-865.

[3.]   Behera D, Epidemiology of lung cancer – Global and Indian perspective Review article JIACM 2012; 13(2): 131-7

[4.]   Binukumar Bhaskarapillai, Saina Sunil Kumar, Satheesan Balasubramanian lung cancer in Malabar Cancer Centre in Kerala- A Descriptive Analysis. Asian Pacific Journal of Cancer Prevention, Vol 13, 2012 .

[5.]   Choong NW, Salgia R, Vokes EE. Key signaling pathways and targets in lung cancer therapy. Clin Lung Cancer 2007; 8 Suppl 2: S52-S60

[6.]   Dhananjay Saranath and Aparna Khanna, Current Status Of Cancer Burden: Global And Indian Scenario. Biomedical Research Journal, 2014;1(1):1-5

[7.]   Dunagan D, Chin R Jr, McCain T, Case L, Harkness B, Oaks T, et al. Staging by positron emission tomography predicts survival in patients with non-small cell lung cancer. Chest 2001; 119(2): 333-339

[8.]   Edwards SL, Roberts C, McKean ME, et al. Preoperative histological classification of primary lung cancer: accuracy of diagnosis and use of the non-small cell category. J Clin Pathol 2000;53:537–540.

[9.]   GLOBCAN facts and figures 2012

[10.]   Hiroshi Haneda, Hidefumi Sasaki, Osamu Kawano, et al. A Correlation Between EGFR Gene Mutation Status And Bronchoalveolar Carcinoma Features In Japanese Patients With Adenocarcinoma; Jpn J Clin Oncol2006;36(2)69-75

[11.]   IARC. Monographs on the Evaluation of Carcinogenic Risks to Humans VOLUME 83 Tobacco Smoke and Involuntary Smoking. 2004.

[12.]   Kerr K. M, Bubendorf L, Edelman M. J, Marchetti A, Mok5 T, Novello S, O’Byrne K, Stahel, S. Peters R, Felip E & Panel Members. Second ESMO consensus conference on lung cancer: pathology and molecular biomarkers for non-small-cell lung cancer ;Annals of Oncology 25: 1681–1690, 2014.

[13.]   Murrey and nadal’s trxt book of respiratory medicine. Fifth edition.

[14.]   NCCN Guidelines for Patients. Lung Cancer Screening, Version 1.2014

[15.]   Ordóñez NG: Value of thyroid transcription factor-1, E-c adherin, BG8, WT1, and CD44S immunostaining in distinguishing epithelial pleural mesothelioma from pulmonary and nonpulmonary adenocarcinoma. Am J Surg Pathol 24:598-606, 2000

[16.]   Ou SH, Zell JA. Carcinoma NOS is a common histologic diagnosis and is increasing in proportion among non-small cell lung cancer histologies. J Thorac Oncol 2009;4:1202–1211

[17.]   Pham DK, Kris MG, Riely GJ. Use of cigarette-smoking history to estimate the likelihood of mutations in epidermal growth factor receptor gene exons 19 and 21 in lung adenocarcinomas. J Clin Oncol 2006; 24: 1700–1704.

[18.]   Rossi G, Pelosi G, Graziano P, Barbareschi M, Papotti M. A reevaluation of the clinical significance of histological subtyping of non–small-cell lung carcinoma: diagnostic algorithms in the era of personalized treatments. Int J Surg Pathol 2009;17:206–218

[19.]   Sequist LV, Joshi VA, Janne PA, Muzikansky A, Fidias P, Meyerson M, Haber DA, Kucherlapati R, Johnson BE, Lynch TJ: Response to treatment and survival of patients with non-small cell lung cancer undergoing somatic EGFR mutation testing. Oncologist 2007, 12:90–98

[20.]   Shanmugapriya Shankar, Vijayalakshmi Thanasekaran1, Dhanasekar1 T, Prathiba Duvooru, Clinicopathological and immunohistochemical profile of non–small cell lung carcinoma in a tertiary care medical centre in South India. Lung India • Vol 31 • Issue 1 • Jan - Mar 2014

[21.]   Sheikh HA, Fuhrer K, Cieply K, Yousem S. p63 expression in assessment of bronchioloalveolar proliferations of the lung. Mod Pathol 2004;17:1134–40.

[22.]   Sheppard MN: Specific markers for pulmonary tumours. Histopathology 36:273-276, 2000

[23.]   Stenhouse G, Fyfe N, King G, Chapman A, Kerr K M. Thyroid transcription factor 1 in Pulmonary adenocarcinoma; J Clini Pathol 2004; 57:383-387.

[24.]   Swerdlow AJ, Peto R, Doll R. Epidemiology of cancer. In: Oxford Textbook of Medicine. Oxford, UK: Oxford University Press; 2010:299–332.

[25.]   Travis WD, Rekhtman N, Riley GJ, et al. Pathologic diagnosis of advanced lung cancer based on small biopsies and cytology: a paradigm shift. J Thorac Oncol 2010;5:411–414.

[26.]   Tsao AS, Tang XM, Sabloff B. Clinicopathologic characteristics of the EGFR gene mutation in non-small cell lung cancer. J Thorac Oncol 2006; 1: 231–239.

[27.]   Valsamo K. Anagnostou, Konstantinos N. Syrigos, Gerold Bepler, Robert J. Homer, and David L. Rimm. Thyroid Transcription Factor 1 Is an Independent Prognostic Factor for Patients With Stage I Lung Adenocarcinoma; JOURNAL OF CLINICAL ONCOLOGY:VOLUME 27:NUMBER 2:JANUARY 10 2009.

[28.]   Zhou C, Wu YL, Chen G. Erlotinib versus chemotherapy as first-line treatment for patients with advanced EGFR mutation-positive non small-cell lung cancer (OPTIMAL, CTONG-0802): a multicentre, open-label randomized phase 3 study. Lancet Oncol 2011; 12: 735–7429

Abstract:

Background: Cocaine is responsible for LV systolic dysfunction in patients (long-term users or with acute intoxication). The mechanism leading to develop cocaine-induced cardiomyopathy is not completely understood, however development of a coronary thrombus, increased oxidative stress, calcium flux sympathomimetic effects are contributing factors in its pathophysiologic formation.

Case Report: A 23 year old B.Tech third year student from top of north India was admitted in cardiac emergency department with complaint of severe breathlessness and pink frothy sputum. ECG showed sinus tachycardia, hyperacute T waves without any ST elevation and depression or T wave inversion. He denied previous history of hypertension, diabetes, thyroid, asthma or tuberculosis and trauma or surgery. He stated us his personal history about cocaine abuser almost 7 years 6 to 8 times per month. On examination he was hypertensive and tachycardic with low Oxygen saturation (70%). Lab data showed an elevated Brain natriuretic peptide; urine toxicology was positive for cocaine. 2D-echocardiography showed dilated left ventricle with poor LV systolic function LVEF-30%. Coronary angiography revealed LAD spasm without any obstructive lesions, subsequently NTG infusion was given and final result was TIMI 3 flow in coronaries. He was managed medically and subsequently discharged with drug rehabilitation. On follow-up diagnostic evaluation after 6 months of cocaine cessation, his ejection function improved significantly.

Conclusion: Cocaine is a potent sympathomimetic agent associated with the development of possible fatal cardiovascular complications. Hypertension, Dilated cardiomyopathy, Dysrhythmias and Acute myocardial infarction are just some of many cardiovascular effects related to the abuse of cocaine. The management is like other forms of cardiomyopathy; however β-blockers should be avoided. Non-invasive testing should be performed after several months to re-evaluate the treatment response.

Keywords: Cocaine, Left Ventricle Systolic dysfunction, Heart Failure

References:

[1.]   Abraham JR, Butany J, Leong S, Luk A, Phillips K, Soor GS. Cocaine cardiotoxicity a review of the pathophysiology, pathology, and treatment options. Am J Cardiovasc Drugs. 2009;9(3):177–196. doi: 10.1007/BF03256574.

[2.]   Afonso L, Mohammad T, Thatai D. Crack whips the heart: a review of the cardiovascular toxicity of cocaine. Am J Cardiol. 2007;100:1040–1043. doi: 10.1016/j.amjcard.2007.04.049.

[3.]   Arora S, Alfayoumi F, Srinivasan V. Transient left ventricular apical ballooning after cocaine use: is catecholamine cardiotoxicity the pathologic link? Mayo Clin Proc. 2006; 81: 829– 832.

[4.]   Aslibekyan S, Levitan EB, Mittleman M. Prevalent cocaine use and myocardial infarction. Am J Cardiol. 2008; 102: 966– 969.

[5.]   Bertolet BD, Freund G, Martin CA, Perchalski DL, Williams CM, Pepine CJ. Unrecognized left ventricular dysfunction in an apparently healthy cocaine abuse population. Clin Cardiol. 1990; 13: 323– 328.

[6.]   Brickner ME, Willard JE, Eichhorn EJ, Black J, Grayburn PA. Left ventricular hypertrophy associated with chronic cocaine abuse. Circulation. 1991; 84: 1130–1135.

[7.]   Carrillo J, Marmol-Velez A, Martinez S, Restrepo CS, Riascos R, Rojas CA, Vargas D. Cardiovascular complications of cocaine: imaging findings. Emerg Radiol. 2009;16:11–19. doi: 10.1007/s10140-008-0762-x.

[8.]   Diercks DB, Fonarow GC, Kirk JD. Illicit stimulant use in a United States heart failure population presenting to the emergency department (from the Acute Decompensated Heart Failure National Registry Emergency Module). Am J Cardiol.2008; 102: 1216– 1219.

[9.]   Egashira K, Morgan KG, Morgan JP. Effects of cocaine on excitation-contraction coupling of aortic smooth muscle from the ferret. J Clin Invest. 1991;87: 1322– 1328.

[10.]   Figueredo VM. Chemical cardiomyopathies: the negative effects of medications and nonprescribed drugs on the heart. Am J Med. 2011;124:480–488. doi: 10.1016/j.amjmed.2010.11.031.

[11.]   Figueredo VM, Maraj S, Morris DL. Cocaine and the heart. Clin Cardiol. 2010;33(5):264–269. doi: 10.1002/clc.20746.

[12.]   Fischman MW, Schuster CR, Resnekov L, Shick JF, Krasnegor NA, Fennell W, Freedman DX. Cardiovascular and subjective effects of intravenous cocaine administration in humans. Arch Gen Psychiatry. 1976; 33: 983– 989.

[13.]   Flores ED, Lange RA, Cigarroa RG, Hillis L. Effect of cocaine on coronary artery dimensions in atherosclerotic coronary artery disease: enhanced vasoconstriction at sites of significant stenoses. J Am Coll Cardiol. 1990; 16: 74–79.

[14.]   Fraker TD Jr, Madu EC, Mouhaffel AH, Satmary WA. Cardiovascular complications of cocaine. Chest. 1995;107(5):1426–1434. doi: 10.1378/chest.107.5.1426.

[15.]   Gardin JM, Wong N, Alker K, Hale SL, Paynter J, Knoll M, Jamison B, PattersonM, Kloner R. Acute cocaine administration induces ventricular regional wall motion and ultrastructural abnormalities in an anesthetized rabbit model. Am Heart J. 1994; 128: 1117– 1129.

[16.]   Hale SL, Alker KJ, Rezkalla S, Figures G, Kloner RA. Adverse effects of cocaine on cardiovascular dynamics, myocardial blood flow, and coronary artery diameter in an experimental model. Am Heart J. 1989; 118: 927– 933.

[17.]   Hale SL, Alker KJ, Rezkalla SH, Eisenhauer AC, Kloner RA. Nifedipine protects the heart from the acute deleterious effects of cocaine if administered before but not after cocaine. Circulation. 1991; 83: 1437– 1443.

[18.]   Hale SL, Lehmann MH, Kloner RA. Electrocardiographic abnormalities after acute administration of cocaine in the rat. Am J Cardiol. 1989; 63: 1529– 1530.

[19.]   Havranek EP, Nademanee K, Grayburn PA, Eichhorn EJ. Endothelium-dependent vasorelaxation is impaired in cocaine arteriopathy. J Am Coll Cardiol.1996; 28: 1168– 1174.

[20.]   Heesch CM, Wilhelm CR, Ristich J, Adnane J, Bontempo FA, Wagner WR. Cocaine activates platelets and increases the formation of circulating platelet containing microaggregates in humans. Heart. 2000; 83: 688– 695.

[21.]   Kelly RF, Sompalli V, Sattar P, Khankari K. Increased TIMI frame counts in cocaine users: a case for increased microvascular resistance in the absence of epicardial coronary disease or spasm. Clin Cardiol. 2003; 26: 319– 22.

[22.]   Kugelmass AD, Oda A, Monahan K, Cabral C, Ware JA. Activation of human platelets by cocaine. Circulation. 1993; 88: 876– 883.

[23.]   Lange RA, Cigarroa RG, Yancy CW Jr., Willard JE, Popma JJ, Sills MN, McBrideW, Kim AS, Hillis LD. Cocaine-induced coronary-artery vasoconstriction. N Engl J Med. 1989; 321: 1557– 1562.

[24.]   Mo W, Singh AK, Arruda JA, Dunea G. Role of nitric oxide in cocaine-induced acute hypertension. Am J Hypertens. 1998; 11: 708– 714.

[25.]   Moliterno DJ, Willard JE, Lange RA, Negus BH, Boehrer JD, Glamann DB, Landau C, Rossen JD, Winniford MD, Hillis LD. Coronary-artery vasoconstriction induced by cocaine, cigarette smoking, or both. N Engl J Med. 1994; 330: 454–459.

[26.]   Moliterno DJ, Lange RA, Gerard RD, Willard JE, Lackner C, Hillis LD. Influence of intranasal cocaine on plasma constituents associated with endogenous thrombosis and thrombolysis. Am J Med. 1994; 96: 492– 496.

[27.]   Om A, Warner M, Sabri N, Cecich L, Vetrovec G. Frequency of coronary artery disease and left ventricle dysfunction in cocaine users. Am J Cardiol. 1992; 69:1549– 1552.

[28.]   Pitts WR, Vongpatanasin W, Cigarroa JE, Hillis LD, Lange RA. Effects of the intracoronary infusion of cocaine on left ventricular systolic and diastolic function in humans. Circulation. 1998; 97: 1270– 1273.

[29.]   Przywara DA, Dambach GE. Direct actions of cocaine on cardiac cellular electrical activity. Circ Res. 1989; 65: 185– 192.

[30.]   Rezkalla SH, Mazza JJ, Kloner RA, Tillema V, Chang SH. Effects of cocaine on human platelets in healthy subjects. Am J Cardiol. 1993; 72: 243– 246.

[31.]   Rinder HM, Ault KA, Jatlow PI, Kosten TR, Smith BR. Platelet alpha-granule release in cocaine users. Circulation. 1994; 90: 1162– 1167.

[32.]   Tazelaar HD, Karch SB, Stephens BG, Billingham ME. Cocaine and the heart. Hum Pathol. 1987; 18: 195– 199.

[33.]   Tong W, Lima JA, Meng Q, Flynn E, Lai S. Long-term cocaine use is related to cardiac diastolic dysfunction in an African-American population in Baltimore, Maryland. Int J Cardiol. 2004; 97: 25– 28.

[34.]   Vita JA, Treasure CB, Fish D, Yeung AC, Vekshtein VI, Ganz P Selwyn AP Endothelial dysfunction leads to increased coronary constriction to catecholamines in patients with early atherosclerosis. J Am Coll Cardiol. 1990; 15: 158A.

[35.]   Virmani R, Robinowitz M, Smialek JE, Smyth DF. Cardiovascular effects of cocaine: an autopsy study of 40 patients. Am Heart J. 1988; 115: 1068– 1076.

[36.]   Vongpatanasin W, Mansour Y, Chavoshan B, Arbique D, Victor RG. Cocaine stimulates the human cardiovascular system via a central mechanism action. Circulation. 1999; 100: 497– 502.

[37.]   Wilbert-Lampen U, Seliger C, Zilker T, Arendt RM. Cocaine increases the endothelial release of immunoreactive endothelin and its concentrations in human plasma and urine: reversal by coincubation with sigma-receptor antagonists. Circulation. 1998; 98: 385– 390.

[38.]   Weber JE, Hollander JE, Murphy SA, Braunwald E, Gibson CM. Quantitative comparison of coronary artery flow and myocardial perfusion in patients with acute myocardial infarction in the presence and absence of recent cocaine use. J Thromb Thrombolysis. 2002; 14: 239– 245.

[39.]   Willens HJ, Chakko SC, Kessler KM. Cardiovascular manifestations of cocaine abuse: a case of recurrent dilated cardiomyopathy. Chest. 1994; 106: 594– 600.

Abstract:

Objective: This study was carried out to assess the literacy of Autism Spectrum Disorder among clinical year medical student in Malaysia.

Methodology: This was a quantitative approach study in which the data was assessed cross-sectional and descriptively. The target population of this study was clinical year medical students from private and public universities. The data was collected through the method of multi-stage sampling which includes cluster and simple random sampling.

Results: Of the 210 clinical year medical students that responded to our study, 70(33.3%) were males and 140(66.7%) were females. There were more students from private universities 179(85.2%) compared to public universities 31(14.8%). The total mean score on belief about autism was 3.84±1.36 out of the maximum 7. There were only 6 (2.9%) out of 210 students who considered to have no misconception on ASD. The total mean score on knowledge was 12.93±3.56 out of 19. It was reported that only 3 (1.4%) students out of 210 considered to have adequate knowledge. The findings in this study showed that there was lack of appropriate attitude of the clinical year medical students towards autistic individuals.

Conclusion: The recognition of the clinical year medical students in Malaysia regarding ASD is low as we can see that there are only 2.9% of the students have accurate belief and 1.4% of students have adequate knowledge about ASD. There are 85.7% of the students who see the autistic individual as normal individual, which to say that there are still presence of 14.3% who see them as abnormal. Thus, this shows that there are still certain level of stigmatization or discrimination which occurred. Belief and attitudes toward autistics can be improved in such a way that medical students would be exemplary to the public on the way autistics should be treated. Ignorance is due to the lack of knowledge thus, medical students should be equipped to educate the public regarding autism to eliminate the existing ignorance that can be seen in the public’s attitude towards autism.

References:

[1.]   Arif, M. M., Ayesha Niazy, Bilal Hassan, & Farah Ahmed. (2013). Awareness of Autism in Primary School Teachers. (M. V. Pletnikov, Ed.) Autism Research and Treatment, 1-5.

[2.]   Autism Speaks Inc. (n.d.). What is Autism? Retrieved from Autism Speaks: https://www.autismspeaks.org/what-autism

[3.]   Autism Speaks Organization. (n.d.). What is Autism? Retrieved from Autism Speaks: https://www.autismspeaks.org/what-autism

[4.]   Bakare, M. O., M. F. TundeAyinmode, A. O. Adewuya, M. A. BelloMojeed, S. Sale, B. O. James, . . . A. O. Orovwigho. (2015). Recognition of Autism Spectrum Disorder (ASD) symptoms and knowledge about some other aspects of ASD among final year medical students in Nigeria, SubSaharan Africa. BMC Research Notes, 1-8.

[5.]   Bakare, M. O., Peter O Ebigbo, Ahamefule O Agomoh, & Nkem C Menkiti. (2008). Knowledge about childhood autism among health workers (KCAHW) questionnaire: description, reliability and internal consistency. Clinical Practice and Epidemiology in Mental Health, 1-8.

[6.]   BERNAMA. (2014, March 28). With support, autistic children can move on. Retrieved from The Malaysian Times: http://www.themalaysiantimes.com.my/with-support-autistic-children-can-move-on/

[7.]   Broder-Fingert, S., Christine F. Ferrone, Ann Giauque, & Susan L. Connors. (2014). Residents’ Knowledge and Comfort With Caring for Children With Autism Spectrum Disorder. Clinical Pediatrics, 1390-1392.

[8.]   Campbell, D. J., David N. Ellis, Abigail Baxter, & Keith Ni. (2007). Alabama Autism Awareness Assessment.

[9.]   Campbell, L. (2008). An Assessment of Autism Knowledge in the Medical Field. 1-90.

[10.]   Centers for Disease Control and Prevention. (2015, August 12). Facts About ASD. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/ncbddd/autism/facts.html

[11.]   Croen, A., Grether, J.K. , Hoogstrate, J. , & Selvin, S. (2002). Descriptive Epidemiology of autism in California population: Who is at risk?. Journal of Autism and Developmental Disorders, 32, 217–224.

[12.]   Daley TC, S. M. (2002). Diagnostic Conceptualization of Autism among Indian Psychiatrist, Psychologist and Pediatrician. J Autism Developmental Disorder, 13-23.

[13.]   Daugherty, C. (2012). The Knowledge and Awareness of Autism Spectrum Disorders within the Hispanic Community. 1-17.

[14.]   DeStefano, F., Cristofer S. Price, & Eric S. Weintraub. (2013). Increasing Exposure to Antibody-Stimulating Proteins and Polysaccharides in Vaccines Is Not Associated with Risk of Autism. The Journal of Paediatrics, 561-567. Retrieved from Vaccines Do Not Cause Autism: http://www.jpeds.com/article/S0022-3476(13)00144-3/pdf?ext=.pdf

[15.]   DeVilbiss, E. A., & Brian K. Lee. (2014). Brief Report: Trends in U.S. National Autism Awareness from 2004 to 2014: The Impact of National Autism Awareness Month. Journal of Autism & Developmental Disorders, 3271-3273.

[16.]   Diagnostic and Statistical Manual of Mental Disorder Fifth Edition DSM-5. (2013). Washington, DC: American Psychiatric Publishing.

[17.]   Dillenburger, K., Julie-Ann Jordan, & Lyn McKerr. (2013). Autism Spectrum Disorder:Public awareness and attitudes. Research Update.

[18.]   Dillenburger, K., Lynne McKerr, & Julie-Ann Jordan. (2015). Children and young people’s awareness, knowledge, and attitudes towards autism in Northern Ireland. Research Update.

[19.]   Durand-Zaleski, Jan Scott, Frédéric Rouillon, & Marion Leboyer. (2012). A first national survey of knowledge, attitudes and behaviours towards schizophrenia, bipolar disorders and autism in France. BMC Psychiatry 2012, 8.

[20.]   Edyvean, C. (n.d.). Attitudes Toward Autism: Reducing Discrimination with Contact. 1-22.

[21.]   Haimour, A. I., & Yahia F. Obaidat. (2013). School Teachers’ Knowledge about Autism in Saudi Arabia. World Journal of Education, 45-56.

[22.]   Hansen, L. K. (2015). Development and Validation of a Survey of Knowledge of Autism Spectrum Disorder. 1-75.

[23.]   Harrison, A. J., B. L. Cochran, & K. K. Blane. (2015). ASD Knowledge and Stigmas in Tanzania.

[24.]   Heidgerken, A. D., Gary Geffken, Avani Modi, & Laura Frakey. (2005). A Survey of Autism Knowledge in a Health Care Setting. Journal of Autism and Developmental Disorders, 323-330.

[25.]   Igwe, M. N., Muideen O Bakare, Anthony C Ahanotu, Justin U Achor, & Chinonyerem Igwe. (2011). Assessment of knowledge about childhood autism among paediatric and psychiatric nurses in Ebonyi state, Nigeria. Child and Adolescent Psychiatry and Mental Health, 1-8.

[26.]   Imran, N., Mansoor R Chaudry, Muhammad W Azeem, Muhammad R Bhatti, Zaidan I Choudhary, & Mohsin A Cheema. (2011). A survey of Autism knowledge and attitudes among the healthcare professionals in Lahore, Pakistan. BMC Pediatrics, 1-6.

[27.]   K., S. (2001). Research in brief: what do medical students know about autism? Autism, 127-133.

[28.]   Khemlani, A. (2015, December 14). Autism Awareness. Spotlight Health Care, p. 17 & 25.

[29.]   Laura Simmons. (2008). Think differently-act positively. London: The National Autistic Society.

[30.]   Ministry of Education. (2012, September). The Ministry of Education Malaysia Preliminary Report of National Education Blueprint 2013-2025. Retrieved from Kementerian Pendidikan Malaysia: http://www.moe.gov.my/userfiles/file/PPP/Preliminary-Blueprint-Eng.pdf

[31.]   Ministry of Health. (2014). Management Of Autism Spectrum Disorder In Children and Adolescents. Putrajaya: Malaysia Health Technology Assessment Section (MaHTAS).

[32.]   Nair, R. (2015). Challenges, Strategies and Success Gained By a Teacher in Teaching Autism Students in a Private Centre. International Journal of Social Science and Humanities Research, 419-425.

[33.]   National Institute of Mental Health. (n.d.). Autism Spectrum Disorder. Retrieved from National Institute of Mental Health: http://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd/index.shtml

[34.]   O'Leary, M. B. (2014, February 27). Study reveals why autism is more common in males. Retrieved from ELSEVIER: https://www.elsevier.com/connect/study-reveals-why-autism-is-more-common-in-males

[35.]   Pipkin, L. M. (2011). Physician assistants' knowledge and attitudes regarding Autism. 1-43.

[36.]   Rahbar MH, I. K. (2011). Knowledge and attitudes of general practitioners regarding Autism in Karachi, Pakistan. Journal of Autism and Developmental Disorder, 465-474.

[37.]   Rhoades, R. A., Angela Scarpa, & Brenda Salley. (2007). The importance of physician knowledge of autism spectrum disorder: results of a parent survey. BMC Pediatrics, 7-37.

[38.]   See, C. M. (2012). The Use of Music and Movement Therapy to Modify Behaviour of Children with Autism. 1103-1116.

[39.]   Shaukat, F., Fatima, A., Zehra, N., Hussein, M. A., & Ismail, O. (2014). Assessment of knowledge about childhood autism among medical students from private and public universities in Karachi. Journal of the Pakistan Medical Association, 1331-1334.

[40.]   Small, S. H. (2012). Autism Spectrum Disorders (ASD): Knowledge, Training, Roles and Responsibilities of School Psychologists. 1-220.

[41.]   Stone, W. (1987). Cross‐disciplinary perspectives on autism. Journal of Pediatric, 615‐630.

[42.]   Suhaily, b., & Siti Syuhada, b. (2014). A PRELIMINARY STUDY: AWARENESS, KNOWLEDGE AND ATTITUDE OF PEOPLE TOWARDS CHILDREN WITH AUTISM. Proceeding of the Social Sciences Research ICSSR 2014, 322-332.

[43.]   Surmen, A., Seyhan Hidiroglu, Hamide Hande Usta, Muhammed Awiwi, Ahmet Saki Oguz, Melda Karavus, & Ahmet Karavus. (2015). A study exploring knowledge, attitudes and behaviours towards autism among adults applying to a Family Health Center in Istanbul. North Clin Istanbul, 13-18.

[44.]   The National Autism Society of Malaysia. (n.d.). What Is Autism? Retrieved from NASOM The National Autism Society of Malaysia: http://www.perkobp.org/Image/What%20is%20Autism1.pdf

[45.]   Tipton, L. A., & Jan Blacher. (2014). Brief Report: Autism Awareness: Views from a Campus Community. Journal of Autism & Developmental Disorders, 477-483.

[46.]   Wang, J., Zhou, X., Xia, W., Sun, C., Wu, L., & JianLi. (2011). Autism awareness and attitudes towards treatment in caregivers of children aged 3-6 years in Harbin, China. Social Psychiatry & Psychiatric Epidemiology, 1301-1308.

[47.]   Yasar, P., & Kathleen A. Cronin. (2014). Perspectives of College of Education Students in Turkey on Autism Spctrum Disorders. INTERNATIONAL JOURNAL OF SPECIAL EDUCATION, 1-15.

[48.]   Yayasan Sime Darby. (2014, April 30). Yayasan Sime Darby Wraps Up Autism Awareness Month with Grant to Assist Autistic Children from Poor Families. Retrieved from Yayasan Sime Darby: http://www.yayasansimedarby.com/1405210849%C2%BBYayasan_Sime_Darby_Wraps_Up_Autism_Awareness_Month_with_Grant_to_Assist_Autistic_Children_from_Poor_Families.aspx

[49.]   York, A., N. von Fraunhofer, J. Turk, & P. Sedgwick. (1999). Fragile-X syndrome, Down's syndrome and autism: awareness and knowledge amongst special educators. Journal of Intellectual Disability Research, 314-324.

[50.]   YS, K., BL, L., YJ, K., E, F., E, L., & EC, L. (2011). Prevalence of autism spectrum disorders in a total population sample.

Abstract:

Background: Marfan syndrome is an autosomal dominant connective tissue disorder characterized by a combination of clinical manifestations in different organ systems. Patients with Marfan syndrome (MFS) whose lifetimes are extended may be encountered as acute abdomen cases (Aortic dissection) apart from the obligatory reasons and emergencies arising naturally out of their disease, as in the case reported. Ebstein’s anomaly is a rare congenital heart disease; in which there is a downward displacement of the tricuspid valve into the right ventricle.

Case Report: 25-year-old Indian male shopkeeper, 47 kg in weight and 176 cm tall was admitted in emergency department with acute abdominal pain associated with dyspnea. Long arms and legs, arachnodactyly, kyphoscoliosis, pectus excavatum were found to be present in the physical examination. According to chest radiography, density increase in the left apical field (hyperluscency) (thought to be secondary to bullous structure), transpiring in the ascendent aorta, a rightward shift of the heart (due to the effect of the kyphoscoliosis and pectus excavatum), and thoracolumbar scoliosis (kyphoscoliosis) with a rightward aperture were detected. In addition, according to the echocardiographic examination, Ebstein’s anomaly, Aortic Dissection, Tricuspid Regurgitaion, pulmonary hypertension, and inferior deficiency of mitral, aorta, and tricuspid valves were present. Moreover, a right bundle block (secondary to Ebstein’s anomaly) was observed in the electrocardiographic examination. Finally he was shifted to cardiothoracic surgery unit for surgical repair of aortic dissection and ebstein anomaly.

Conclusion: For cases of Marfan Syndrome (MFS), the risks of which have been detected through a detailed cardiac examination including echocardiography, we believe that they can be operated as emergency cases with close anesthesia management. Mostly ascending aorta is involved with marfan syndrome but in this case evidence of ebstein anomaly is an interesting point towards cardiovascular surgery and learning about management and post op care.

Keywords: Aortic dissection, marfan syndrome, ebstein anomaly.

References:

[1.]   Ades L. Guidelines for the diagnosis and management of Marfan syndrome. Heart Lung Circ. 2007;16:28–30.

[2.]   Attenhofer Jost CH, Connolly HM, Scott CG, Burkhart HM, Warnes CA, Dearani JA. Outcome of cardiac surgery in patients 50 years of age or older with Ebstein anomaly: survival and functional improvement. J Am Coll Cardiol. 2012 Jun 5. 59(23):2101-6.

[3.]   Attie F, Casanova JM, Zabal C, Buendía A, Miranda I, Rijlaarsdam M. Ebstein's anomaly. Clinical profile in 174 patients. Arch Inst Cardiol Mex. 1999 Jan-Feb. 69(1):17-25..

[4.]   Brickner ME, Hillis LD, Lange RA. Congenital heart disease in adults: second of two parts. N Engl J Med. 2000;342:334–342.

[5.]   Brown ML, Dearani JA, Danielson GK, Cetta F, Connolly HM, Warnes CA, et al. Effect of operation for Ebstein anomaly on left ventricular function. Am J Cardiol. 2008 Dec 15. 102(12):1724-7.

[6.]   Brown ML, Dearani JA, Danielson GK, Cetta F, Connolly HM, Warnes CA, et al. Functional status after operation for Ebstein anomaly: the Mayo Clinic experience. J Am Coll Cardiol. 2008 Aug 5. 52(6):460-6.

[7.]   Dean JCS. Management of Marfan syndrome. Heart. 2002;88:97–103.

[8.]   Groves ER. Epidural analgesia for labour in a patient with Ebstein’s anomaly. Can J Anaesth 1995;42(1):77-79.

[9.]   McGoldrick KE. Eye, ear, nose, and throat diseases. In: Fleisher LA, editor. Anesthesia and Uncommon Disease. 5th ed. Philadelphia: Saunders Elsevier; 2006. pp. 6–7.

[10.]   Meijboom LJ, Nolle GJ, Mulder BJM. Prevention of cardiovascular complications in the Marfan syndrome. Vas Disc Prevent. 2004;1:79–86.

[11.]   Mesrobian RB, Epps JL. Midtracheal obstruction after Harrington rod placement in a patient with Marfan’s syndrome. Anesth Analg. 1986;65:411–413.

[12.]   Misa VS, Pan PH. Evidence based case report for analgesic and anaesthetic management of parturient with Ebstein’s anomly and Wolff-Parkinson- White syndrome. Int J Obstet Anesth 2007;16:77-81.

[13.]   Oh AY, Kim YH, Kim BK, et al. Unexpected tracheomalacia in Marfan syndrome during general anesthesia for correction of scoliosis. Anesth Analg. 2002;95:331–332.

[14.]   Oliver WC, Lynch JJ. Congenital heart disease. In: Fleisher LA, editor. Anesthesia and Uncommon Disease. 5th ed. Philadelphia: Saunders Elsevier; 2006. pp. 115–118.

[15.]   Robinson PN, Godfrey M. The molecular genetics of Marfan syndrome and related microfibrillopathies. J Med Genet. 2000;37:9–25.

[16.]   Shores J, Berger KR, Murphy EA, Pyeritz RE. Progression of aortic dilatation and the benefit of long-term beta-adrenergic blockade in Marfan’s syndrome. N Engl J Med. 1994;330:1335–1341.

Abstract:

Pregnancy with hypertension, proteinuria, edema detected in third trimester is always preeclampsia unless proven otherwise¹. We had a similar case with acute onset of hypertension, proteinuia, oedema, mild breathlessness along with frank hematuria at 32 weeks of gestation in a primigravida. She was initially diagnosed as preeclampsia with its complication either HELLP syndrome or DIC. Investigations showed sever anaemia, mild thrombocytopenia normal liver & kidney function normal coagulation studies without any evidence of sepsis. Surprisingly fetal parameters were absolulety normal. There was no evidence of Intrauterine Growth restriction, fetal, and uterine Doppler studies were normal. Renal Doppler showing paranchymal renal disease. Patient was stabilized in ICU with nasal Oxygen, diuretics, antihypertensive, antibiotics, steroids for fetal pulmonary maturity. In view of deteriorating maternal condition uncontrolled hypertension increasing hematuria urgent delivery by caesarian section done as bishops was very poor. Surgery went uneventful with outcome of male child of 1.7 kgs. Post surgery patient was hemodynamically stable hypertension well controlled but hematuria was persistent and fluctuant. Urine culture report was negative. Suspecting some renal pathology with nephritic syndrome like presentation, she was found to be ASO titer positive. Detailed history revealed pharyngitis 4-5 days before with altered voice since then. Repeat renal uitrasonography 15 days postdelivery showed same findings of altered corticomedullary differentiation, raised cortical echogenicity suggestive of medical renal disease with normal renal artery Doppler. Final diagnosis of nephritic syndrome was made and patient was discharged on day 16 with fluctuant hematuria. Hematuria completely cured over 3 months period.

References:

[1.]   http:// www.merck.com/mmpe/sec17/ch235b.html

[2.]   Julia B. Lewis, Eric G, Neilson: Glomerular diseases; Harrison Principles of Internal Medicine 17^th edition, chp 277 page1784, editor: Anthony S. Fauci.

[3.]   Julia B. Lewis, Eric G, Neilson: Glomerular diseases; Harrison Principles of Internal Medicine 17^th edition, chp 277 page1785-87, editor: Anthony S. Fauci.

[4.]   McGraw – Hill, Williams Obstetrics, 23 ed, Chapt 34, Pregnancy Hypertension.

[5.]   McGraw – Hill, Williams Obstetrics, 23 ed, Chapt 48. Renal and Urinary Tract Disorders.

[6.]   Sibai M, Renal Diseases & Pregnancy B, Glob.libr.womens med, Glowm.10157, 2008.

Abstract:

Two points worth noting about osteoporosis in India - high incidence among men and lower age of peak incidence compared to Western countries. 1 out of 8 males and 1 out of 3 females in India suffers from osteoporosis. The incidence of hip fracture is 1 woman to 1 man. In Western countries, the peak incidence of osteoporosis occurs at 70-80 years of age, in India it afflicts at age 50-60. But there is a worrying trend of increasing prevalence of osteoporosis among the younger men in India that has been under studied. This cross-sectional study was conducted in a tertiary care centre. With informed consent, male subjects were evaluated clinically including anthropometry and history, biochemically with 25-OH Vitamin D and radiologically with DEXA scan. Calculation of T score and categorization as osteoporosis, osteopenia, and normal BMD was done as per WHO classification and data was analyzed. The male population having decreased bone mass was more than expected. Osteoporosis and osteopenia are prevalent in younger male population too contrary to the popular belief. A significantly large proportion of south Indian men had osteoporosis and vitamin D deficiency. Further interventional studies are needed to look at reduction in end points like fractures and morbidity in these subjects.

References:

[1.]   Agrawal N. K and. Sharma B, “Prevalence of osteoporosis in otherwise healthy Indian males aged 50 years and above,” Archives of Osteoporosis, vol. 8, no. 1-2, article no. 116, 2013.

[2.]   Arya V, Bhambri R and Godbole MM(2004) Vitamin D status and its relationship with bone mineral density in healthy Asian Indians. Osteoporosis Int 15:56–61.

[3.]   Bliuc D,. Nguyen N. D,. Milch V. E,. Nguyen T. V,. Eisman J. A, and. Center J. R, “Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women,” JAMA—Journal of the American Medical Association, vol. 301, no. 5, pp. 513–521, 2009.

[4.]   Center JR, Nguyen TV, Schneider D et al (1999) Mortality after all major types of osteoporotic fractures in men and women: an observational study. Lancet 353:878–882.

[5.]   Center J. R.,. Nguyen T. V,. Schneider D,. Sambrook P. N, and. Eisman J. A, “Mortality after all major types of osteoporotic fracture in men and women: an observational study,” The Lancet, vol. 353, no. 9156, pp. 878–882, 1999.

[6.]   Chapuy MC, Arlot ME, Duboeuf F, Brun J, Crouzet B and Arnaud S (1992) Vitamin D3 and calcium to prevent hip fractures in the elderly women. N Engl J Med 327:1637–1642.

[7.]   Ebelin P. R, “Osteoporosis in men,” The New England Journal of Medicine, vol. 358, pp. 1474–1482, 2008.

[8.]   Goswami R, Gupta N and Goswami D (2000) Prevalence and significance of low 25-hydroxyvitamin D concentrations in healthy subjects in Delhi. Am J ClinNutr 72:472–475.

[9.]   Harinarayan C. V and. Joshi S. R, “Vitamin D status in India-its implications and remedial measures, “Journal of Association of Physicians of India, vol. 57, pp. 40–48, 2009.

[10.]   Heaney R. P,. Abrams S,. Dawson-Hughes B et al., “Peak bone mass,” Osteoporosis International, vol. 11, no. 12, pp. 985–1009, 2000.

[11.]   Holick MF (2007) Vitamin D, deficiency. N Engl J Med 357:266 – 281.

[12.]   Kanis J. A,. Johnell O,. Oden A,. Johansson H, and. McCloskey E, “FRAX and the assessment of fracture probability in men and women from the UK,” Osteoporosis International, vol. 19, no. 4, pp. 385–397, 2008.

[13.]   Khanna P, Bhargav S (1971) Roentgen assessment of bone density in north Indian Population. Indian J Med Res 59:1599–1609

[14.]   Lekamwasam S, Wijayaratne L and Rodrigo M (2009) Prevalence and determinants of osteoporosis among men aged 50 years or more in Sri Lanka: a community-based cross-sectional study. Arch Osteoporos 4:79–84.

[15.]   Malhotra N and. Mithal A, “Osteoporosis in Indians,” Indian Journal of Medical Research, vol. 127, no. 3, pp. 263–268, 2008.

[16.]   Marwaha RK, Tandon N and Garg MK (2011) Bone health in healthy Indian population aged 50 years and above. Osteoporos Int 22:2829–2836.

[17.]   Melton L. J III,. Atkinson E. J,. O'Connor M. K,. O'Fallon W. M, and. Riggs B. L, “Bone density and fracture risk in men,” Journal of Bone and Mineral Research, vol. 13, no. 12, pp. 1915–1923, 1998.

[18.]   Rao S. S, Budhwar N., and Ashfaque A., “Osteoporosis in men,” American Family Physician, vol. 82, no. 5, pp. 503–508, 2010.

[19.]   Tandon N, Marwaha RK and Kalra S(2003) Bone mineral parameters in healthy young Indian adults with optimal vitamin D availability. Natl Med J India 16:298–302.

[20.]   Vupputuri MR, Goswami R and Gupta N(2006) Prevalence and functional significance of 25-hydroxyvitamin D deficiency and vitamin D receptor gene.

[21.]   World Health Organization (WHO), “Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: report of a WHO study group,” WHO Technical Report 843, WHO, Geneva, Switzerland, 1994.

[22.]   Zargar AH, Ahmad S and Masoodi SR (2007) Vitamin D status in apparently healthy adults in Kashmir Valley of Indian subcontinent. Postgrad Med J 83:713–716.

Abstract:

The maternal autonomy was measured by the level of participation in household decisions according to the BDHS 2011 scale. The nutritional status of the children was evaluated through measuring height and weight of the children and plotting it in CDC growth reference chart. The study was a cross sectional study which took place in Manikganj district of Bangladesh, on 260 married mothers who have at least one child aged between 1 to 3 years. Our estimation results show that, mother’s level of participation in household decisions found to have significant impact on child’s nutritional outcome, especially in terms of height. Other factors such as, age gap with the husband more than 5 years, early marriage and adolescent pregnancy found to decrease the maternal autonomy condition significantly. On the other hand mother’s living in the single family, with better education and who have their personal income are significantly more autonomous. They also found to be less prone to have stunted children.

Keywords: Maternal autonomy, child nutritional status, rural

References:

[1.] Ahmed S,. Koenig M. A, &. Stephenson R,. ‘Effects of Domestic Violence on Perinatal and Early-Childhood Mortality: Evidence From North India.’. American Journal of Public Health, (2006), Vol.96, No.8, pp.1423-1628.

[2.] Anjor Bhaskar, Does greater autonomy among women provide the key to better child nutrition? June 29(2012)

[3.] Begin F, Frongillo, Delisle, & Habicht, ‘Caregiver behaviors and resources influence child height-for-age in rural Chad’. J Nutr (1999) Vol.129 No.3, pp.680-686

[4.] Bhuiya, M. Chowdhury, ‘Beneficial effects of a woman-focused development programme on child survival: evidence from rural Bangladesh’. Social Science & Medicine (2002), Vol.55 No.9, pp.1553-1560.

[5.] Engle P. L, ‘Maternal work and child-care strategies in peri-urban Guatemala: nutritional effect's’ Child Dev (1991), Vol.62, No.7, pp.954-965

[6.] Gillespie S, &. Haddad L, ‘Attacking the double burden of malnutrition in Asia and the Pacific’ (2001). Vol. ADB Nutrition and Development Series: Asian Development Bank.

[7.] Thomas D, ‘Intra-household resource allocation: An inferential approach’. Journal of Human Resources (1990). Vol.25, pp.635-664.

Abstract:

The common male problem, Gyanecomastia, is truly Pseudo gynaecomastia with only fatty tissue and minimal glandular tissue. The condition is a part of the co existing Obesity disorder and is rarely, a standalone entity. The treatment options shall include an approach to answer the issue of obesity as a whole, not rest contented with surgical removal of the enlarged breasts alone, as what is seen and what is treated is just a tip of the iceberg. Surgical removal of fatty tissue and extrication of glandular tissue by laser liposuction under Tumescent anaesthesia helps in avoiding the sub areolar incision.

References:

[1.]   Barros AC, Sampaio Mde C (2012). “Gynecomastia: physiopathology, evaluation and treatment”. Sao Paolo Medical Journal 130 (3): 187–97. doi:10.1590/s1516-31802012000300009

[2.]   “Breast enlargement in males”. Medline Plus. US National Library of Medicine. Retrieved 15 November 2015.

[3.]   Cordova A, Moschella F (2008). “Algorithm for clinical evaluation and surgical treatment of gynaecomastia”. J Plast Reconstr Aesthet Surg 61 (1): 41–9.doi:10.1016/j.bjps.2007.09.033

[4.]   “Current concepts in gynaecomastia”. Surgeon7 (2): 114–19. doi:10.1016/s1479-666x(09)80026-7

[5.]   Deepinder F, Braunstein GD (2012). “Drug-induced gynecomastia: an evidence-based review.”. Expert opinion on drug safety 11 (5): 779–795.doi:10.1517/14740338.2012.712109

[6.]   Erol S, Orhan E, Sevin A, Erdogan B. Trauma: a new pseudogynecomastia cause. Aesth Plast Surg.2010;34:404–405. doi: 10.1007/s00266-009-9435-8

[7.]   Erol S, Orhan E, Sevin A, Erdogan B. Trauma: a new pseudogynecomastia cause. Aesth Plast Surg.2010;34:404–405. doi: 10.1007/s00266-009-9435-8. [PubMed] [Cross Ref]

[8.]   Narula HS, Carlson HE (August 2014). “Gynaecomastia-pathophysiology, diagnosis and treatment”. Nat Rev Endocrinol 10 (11): 684–698. doi:10.1038/nrendo.2014.139

[9.]   Rohrich RJ, Ha RY, Kenkel JM, Adams WP., Jr Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction. Plast Reconstr Surg. 2003;111:909–923. doi: 10.1097/01.PRS.0000042146.40379.25.

[10.]   Venkata Ratnam B. A new classification and treatment protocol for gynecomastia. Aesth Surg J.2009;29:26–31. doi: 10.1016/j.asj.2008.11.003

[11.]   Wollina, U; Goldman, A (June 2011). “Minimally invasive esthetic procedures of the male breast”. Journal of cosmetic dermatology 10 (2): 150–155. doi:10.1111/j.1473-2165.2011.00548

Abstract:

Background: Large portion of Nigeria’s population use the services of non-formal health care providers like patent medicine vendors (PMV) and traditional birth attendants (TBA), seeing that 65% of deliveries in Nigeria occur in such non-formal health setting. Though studies demonstrate increase in HIV/AID awareness among PMV/TBAs there is yet an unclear evidence of their level of participation in the HIV/AIDS response, even as health financing and engagement of these private sector becomes important implementation research question in Nigeria. This study aims to compare level of awareness versus level of participation of the non-formal health care providers in the HIV/AIDS response in Nigeria.

Method: By cross-sectional design, questionnaire was used to get responses from 210 PMVs and 135 TBAs across 6 Local Government Areas in Ebonyi State, Nigeria. Responses were analyzed using percentages and frequency distribution.

Results: Mean age is 34 years. Highest education level was secondary school at 59%. HIV/AIDS awareness level was >80% but participation was at 48%.

Conclusion: HIV Awareness has increased among TBA/PMV but their participation level in HIV/AIDS response is still low. Integration of this group into public health sector could increase participation.

References:

[1] Abiodun O, Sotunsa J, Ani F, Olaleye A, Taiwo A: Elimination of Mother- To-Child Transmission of HIV in Nigeria: The Roles, Preparedness and Determinants of Successful Involvement of Traditional Birth Attendants. J AIDS Clin Res 2015;6:481.

[2] Catholic Relief Services (CRS) (2004) Training curriculum for traditional birth attendants. http://www.coregroup.org/storage/documents/Diffusion_of_Innovation/trainingAccessed September 2015

[3] François Nankobogo and Nilufar Egamberdi: The Role of Private Sector in the Fight Against HIV/AIDS in Sub-Saharan Africa, Thematic Stakeholder Consultations Bamako, Mali, December 2007; 10:10.

[4] HIV/AIDS Division, Federal Ministry of Health. National Operational Plan for the Elimination of Mother to Child Transmission (EMTCT) of HIV in Nigeria, 2015–2016. 2014. HIV/AIDS Division Federal Ministry of Health, Abuja, Nigeria. Web: www.nascp.gov.ng.

[5] Lagomarsino G, Nachuk S and Kundra SS. Public Stewardship of Private Providers in Mixed Health Systems: Synthesis Report From the Rockefeller Foundation–Sponsored Initiative on the Role of the Private Sector in Health Systems. Washington, DC: Results for Development Institute; 2009.

[6] Ministry of Health. National Sexual and Reproductive Health and Rights Policy 2009: Lilongwe. 2009. http://www.healthpolicyproject.com/pubs/455_FINALPolicyReviewFPHIVIntegration Accessed October 2015

[7] National Population Commission (NPC) [Nigeria] and ICF International. 2014. Nigeria Demographic and Health Survey 2013. https://dhsprogram.com/pubs/pdf/FR293/FR293.pdf Accessed October 2015

[8] Nigel Rollins: Prioritizing National PMTCT Implementation Research, J Acquir Immune Defic Syndr 2014; 67:2

[9] Olumide Abiodun, John Sotunsa, Oluwatosin Olu-Abiodun et al. The Effect of Training on Traditional Birth Attendants’ PMTCT Related Knowledge and Care Practices in Nigeria. J AIDS Clin Res 2015;6:9

[10] Pamela Rao, Tesfai Gabre-Kidan, Deus Bazira Mubangizi, and Sara Sulzbach: Leveraging the Private Health Sector, J Acquir Immune Defic Syndr. August 1 2015;57:2,4.

[11] Sara Sulzbach, Susna De and Wenjuan Wang: The private sector role in HIV/AIDS in the context of an expanded global response: expenditure trends in five sub-Saharan African countries. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. Health Policy and Planning 2011;26:72-84

[12] The Business of Health in Africa: Partnering with the Private Sector to Improve People’s Lives. Washington, DC: International Finance Corporation; 2007.

[13] USAID: Nigeria Private Sector Health Assessment, 2008. http://www.shopsproject.org/sites/default/files/resources/5137_file_FINAL. Accessed October 2015

[14] World Health Organization: WHO Traditional Medicine Strategy; 2014-2023. 2013. Publications of the World Health Organization are available on the WHO web site (www.who.int) assessed September 2015

[15] Wang W, Sulzbach S and De S. Utilization of HIV-related services from the private health sector: a multi-country analysis. Soc Sci Med. 2011; 72: 216–223.