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Based on results of ecological studies demonstrating that Vibrio cholerae, the etiological agent of epidemic cholera, is commensal to zooplankton, notably copepods, a simple filtration procedure was developed whereby zooplankton, most phytoplankton, and particulates >20 microm were removed from water before use. Effective deployment of this filtration procedure, from September 1999 through July 2002 in 65 villages of rural Bangladesh, of which the total population for the entire study comprised approximately 133,000 individuals, yielded a 48% reduction in cholera (P < 0.005) compared with the control.

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OBJECTIVE: Use of the MacCarty keyhole burr hole and the inferior orbital fissure provides simplicity and safety to perform the one-piece frontotemporal orbitozygomatic (FTOZ1) approach. METHODS: We performed the FTOZ1 approach with its three subtypes (i.e., total, temporal, and frontal) in cadaveric head specimens in the Goodyear Laboratory and subsequently in surgical cases. RESULTS: The orbitozygomatic osteotomy, when added to a frontotemporal craniotomy, comprises the frontotemporal orbitozygomatic (FTOZ) approach, provides an expanded exposure to the anterior and middle cranial fossae, and enables the surgeon to create a window to the posterior cranial fossa. The MacCarty burr hole is used to facilitate orbital cuts, and the anterolateral portion of the inferior orbital fissure connects the orbital cuts to the zygomatic cuts. This allows the FTOZ1 craniotomy flap to be "out-fractured" with ease. The three types of FTOZ1 approach, i.e., the total, the temporal, and the frontal, are described step by step. CONCLUSIONS: Understanding the MacCarty keyhole burr hole and the microsurgical anatomy of the inferior orbital fissure is essential to performing the FTOZ1 approach. The three types of FTOZ1 approach enable the surgeon to tailor the approach according to the surgical exposure needed for each lesion.

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A national survey was carried out to achieve the following objectives: (1) construction of national standards for Saudi children, 0-5 years old, with regard to weight, height and head circumference for males and females; (2) construction of a growth chart for weight, height and head circumference for 0-5-year-old Saudi children that can be used at hospitals and health centres in the Kingdom for routine follow-up of the growth of these children. To achieve these objectives, the WHO recommendations were applied. A total of 24,000 Saudi children, 12,000 males and 12,000 females, were selected randomly representing the five regions of the Kingdom with 200 children in each monthly age group. Demographic data as well as the anthropometric measurements were recorded by well-trained personnel using a pretested questionnaire and new, well calibrated equipment. The current study showed that Saudi boys (0-5 years old) were heavier and taller than Saudi girls in the same age group, and that the median weights and heights of Saudi boys and girls (0-5 years old) were more than those of the Harvard standards. A growth chart was constructed which was suitable for growth monitoring programmes all over the Kingdom.

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OBJECTIVE: To determine parameters that influence the selection of the proper petrosal approach or combined approaches for the excision of petroclival meningiomas. METHODS: We dissected 15 cadaver heads, inspected the petroclival region in 50 dry human skulls, and performed a retrospective analysis of the cases of 35 patients with petroclival meningiomas who underwent surgery via transpetrosal approaches. RESULTS: The petroclival region was divided into three "zones" based on the extent of surgical exposure achieved via the petrosal approaches with microscopic dissection of 15 preserved and silicone-injected cadaveric heads and with the measurements of 50 dry skulls. Zone I, defined as the area from the dorsum sellae to the internal auditory canal, is accessible via the anterior petrosal approach. Zone II, defined as the area from the internal auditory canal to the upper border of the jugular tubercle, is easily accessible in its lateral portion via the posterior petrosal approach. The medial portion of Zone II, the "central clival depression," is accessible only with cochlear resection and posterior facial nerve transposition. Zone III, defined as the area from the upper border of the jugular tubercle to the lower edge of the foramen magnum, is accessible via a suboccipital/transcondylar approach. The retrospective analysis of the cases of 35 patients who underwent transpetrosal resection of petroclival meningiomas between 1991 and 1998 was used to determine the predictive value of these anatomic parameters. The degree of tumor resection was analyzed with a novel grading scale combining the percentage of resection and the percentage of brainstem reexpansion. Total excision was achieved in 37% of the patients and complete brainstem reexpansion was achieved in an additional 40%. Residual tumor was concentrated in the central clival depression in Zone II, as predicted by anatomic parameters, and around infiltrated neurovascular structures. New cranial nerve deficit occurred in 31% of the patients in the early postoperative period and improved to 17% at 6 months. Major morbidity occurred in 9% of the patients, and mortality was 0%. Early Karnofsky scores were reduced in 37% of the patients, but 6-month Karnofsky scores were equal to preoperative baseline scores or improved in 91%. CONCLUSION: Anatomic parameters can predict the resectability of petroclival meningiomas. Judicious application of cytoreductive surgery in selected patients maintains an acceptable morbidity and achieves adequate brainstem reexpansion.

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Integration is an important tool for successful implementation of components of a comprehensive health programme. We describe strategies adopted to integrate the Saudi maternal and child health (MCH) activities with other primary health care (PHC) components in order to achieve optimal quality care. Achieving such integration was one of the specific objectives of the MCH programme. Besides training MCH workers, other important tools of MCH/PHC integration included: organization, supervision, continuing education, data management and health systems research. The strengths and weaknesses of integration are discussed while the opportunities, limitations and implications are reviewed.

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Integration is an important tool for successful implementation of components of a comprehensive health programme. We describe strategies adopted to integrate the Saudi maternal and child health [MCH] activities with other primary health care [PHC] components in order to achieve optimal quality care. Achieving such integration was one of the specific objectives of the MCH programme. Besides training MCH workers, other important tools of MCH/PHC integration included: organization, supervision, continuing education, data management and health systems research. The strengths and weaknesses of integration are discussed while the opportunities, limitations and implications are reviewed

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OBJECTIVE: The dissection of cadaveric specimens is very important for a more sophisticated understanding of neurosurgical anatomic features and approaches. Teaching known approaches to residents or learning new approaches is best performed in a cadaveric laboratory. The utility of neurosurgical cadaveric dissections can be improved by injecting the intracranial vascular tree with colored silicone. The vascular anatomic features, which are integral to neurosurgical procedures, are much more clearly defined in injected specimens. METHODS: Self-curing colored silicone rubber is used to inject the arteries and veins (red and blue, respectively) of the head. This process is described in a step-by-step format. Six steps are required and can be summarized as follows: 1) exposure of the great vessels, 2) cannulation of the great vessels, 3) irrigation of the head, 4) preparation of the colored silicone, 5) injection of the colored silicone, and 6) evaluation of the final specimen. CONCLUSION: Injection of colored silicone into the vascular tree can enhance the educational value of cadaveric head dissections. This report describes the technique of vascular injection that is used in the Goodyear Microsurgical Laboratory, the University of Cincinnati, and the Mayfield Clinic.

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Before the implementation of the two-dose measles immunization policy in Saudi Arabia, 50 per cent of measles cases in children below the age of one year were reported for the age group 6-8 months. In 1991 two doses of measles vaccine, at 6 months and 12 months, the second dose incorporated with MMR, were integrated into the expanded programme of immunization (EPI). Since 1993, vaccination coverage for the second dose has been above 90 per cent. While measles incidence remains stable in infants below 6 months of age, the incidence in children 9-11 months of age dropped by 50 per cent. The greatest impact was seen in the 6-8-month age group where the incidence dropped by more than 75 per cent. Moreover this two-dose strategy resulted in a situation in which 80 per cent of the measles cases were in children above the age of 5 years, mostly those who had not had two doses of measles vaccine. Further control measures should include non-selective vaccination of school children against measles. The two-dose measles vaccination policy is visualized as a necessity if the goal of measles elimination is to be achieved. Routine monthly reports validated by surveys using the WHO standard 30 cluster technique was used for the study.

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OBJECTIVE AND IMPORTANCE: We report the first case of primary lymphoma of Meckel's cave. The ability of a lymphoma to mimic a trigeminal schwannoma, both clinically and radiographically, resulted in misdiagnosis and flawed surgical strategy. We discuss the characteristics of a Meckel's cave lymphoma on magnetic resonance images, the predisposing medical conditions that should cause the neurosurgeon to add lymphoma to the normal differential diagnosis, and appropriate management strategies. CLINICAL PRESENTATION: A 40-year-old African-American woman presented with a 5-month history of progressive facial numbness and pain in all three divisions of the left trigeminal nerve. Magnetic resonance imaging revealed a mass in the left side of Meckel's cave, with extension into the lateral compartment of the cavernous sinus, without encasement of the internal carotid artery, through the foramen rotundum into the posterior aspect of the maxillary sinus, and through the foramen ovale into the pterygopalatine fossa. The diagnosis, based on clinical history and radiographic imaging, was schwannoma of Meckel's cave. The patient had a history of systemic lupus erythematosus that had been treated with intermittent steroid therapy. INTERVENTION: The surgical approach selected was a frontotemporal craniotomy with orbitozygomatic osteotomy and anterior petrosectomy. The lesion was totally excised, although the gross intraoperative appearance of the lesion was inconsistent with the preoperative diagnosis, and the pathological examination was unable to establish a histological diagnosis on the basis of frozen sections. Histological diagnosis was confirmed on permanent section after surgery as B-cell lymphoma. Evaluation for other primary sites produced negative results. The patient was then treated with cyclophosphamide (Cytotoxan; Bristol-Myers Oncology, Princeton, NJ), doxorubicin (Adriamycin; Pharmacia & Upjohn, Kalamazoo, MI), vincristine, and prednisone chemotherapy every 3 weeks for six cycles and then by radiation therapy to the affected area. CONCLUSION: The diagnosis of lymphoma should be considered for lesions affecting Meckel's cave in high-risk immunocompromised patients. The presence of an apparent dural tail in an otherwise typical schwannoma is the distinguishing characteristic of a lymphoma. The absence of hyperostosis helps differentiate it from a meningioma. At this point, the preferred surgical strategy is biopsy for diagnosis and then radiotherapy and chemotherapy rather than major cranial base surgery for total resection.

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Baseline data on acute respiratory infections (ARI) were collected by a survey questionnaire distributed to physicians of 10% of the health centres randomly selected from each of the five provinces of Saudi Arabia. The physicians estimated that ARI was the cause of sickness in 50% of ill children < 5 years in 1995. None of the physicians had had any training in ARI and they were not aware of any national protocol or programme. Physicians' responses indicated an over-use of antibiotics and diagnostic procedures. A national protocol for diagnosis and treatment of ARI has been prepared and distributed and leaders of primary health care and 55 national trainers have been trained.

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Full text is available as a scanned copy of the original print version.

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Baseline data on acute respiratory infections [ARI] were collected by a survey questionnaire distributed to physicians of 10% of the health centres randomly selected from each of the five provinces of Saudi Arabia. The physicians estimated that ARI was the cause of sickness in 50% of ill children < 5 years in 1995. None of the physicians had had any training in ARI and they were not aware of any national protocol or programme. Physicians' responses indicated an over-use of antibiotics and diagnostic procedures. A national protocol for diagnosis and treatment of ARI has been prepared and distributed and leaders of primary health care and 55 national trainers have been trained

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To develop a better and selective medium for the isolation of Shigella spp., MacConkey's Agar (MAC) was modified by adding potassium tellurite (K2TeO3) at a concentration of 1 microgram/ml. The formulation designated Teknaf Enteric Agar (TEA) was studied for the inhibitory effect of potassium tellurite on the growth of different enteric bacteria, and as a medium for isolating Shigella spp. from clinical stool samples (n = 3125). We observed that the growth of E. coli was effectively inhibited on TEA with no effect on the growth of S. dysenteriae type 1 and S. flexneri. A total of 2019 Shigellae were isolated through the combined use of TEA, MAC, and Salmonella-Shigella Agar (SS). On TEA, 1921 S. dysenteriae type 1 and S. flexneri were isolated as compared to 1765 from the combined use of MAC and SS. A total of 194 of S. dysenteriae type 1 and S. flexneri were exclusively isolated from TEA as compared to 38 which were only made from MAC and SS. We conclude that TEA significantly increased the overall isolation rate of Shigella spp. as compared to the combined use of MAC and SS (P < 0.0001), although it is not suitable for the isolation of S. sonnei.

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The in vitro production of haemolysin by Vibrio fluvialis was studied using sheep erythrocyte. The effect of the composition of various media and different concentrations of sodium chloride on the production of haemolysin and heat-stability was investigated. Comparatively higher titre of haemolysin production was noted in brain heart infusion (BHI) broth. Adding 0.5% NaCl to BHI broth reduced the production of haemolysin; adding 5.0% NaCl to the medium totally inhibited it. The highest titre of haemolysin was produced at 30 degrees C and 37 degrees C, whereas no haemolysin was produced at 50 degrees C. Haemolytic activity was totally destroyed when heated at 56 degrees C for 30 minutes. Haemolysin could be assayed easily following this method.

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PIP: The study was undertaken to increase the intake of vegetables rich in beta-carotene by young children through nutrition education of their caregivers. 156 children aged 6-59 months were selected from households of very poor socioeconomic status in the comparison area of Matlab MCH-FP Project. Nutrition education intervention was provided to the caregivers of these children on the importance of feeding vegetables rich in beta-carotene. This education included verbal communication and cooking demonstrations. It was provided by trained female community health workers once every 2 months over a period of 12 months from April 1994 to March 1995. Information on the consumption of green leafy vegetables by the children for the preceding 3 days was collected at baseline and after the 12-month intervention by interviewing the caregivers. The green leafy vegetables were categorized into high, medium, and low contents of beta-carotene. The proportion of children who consumed vegetables with high content of beta-carotene increased from 28% at the baseline to 96% after the intervention, showing a highly significant increase (p .000). The mean frequency of intake of vegetables rose from 0.65 per 3 days at baseline to 4.33 after the intervention. This increase in intake was also highly significant (p .000). The significant increase in the consumption of vegetables was achieved within a period of one year from the intervention. This shows that changes in the feeding practices of young children were feasible through education and motivation, which can develop confidence among the caregivers regarding the beneficial outcome of the recommended foods.^ieng

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An integrated water supply, sanitation and hygiene (WSH) education intervention project was run by the International Centre for Diarrhoeal Disease Research, Bangladesh, over the period 1983-87. In the intervention area the project provided handpumps, pit latrines, and hygiene education to about 800 households. The control population did not receive any interventions, but had access to the usual government and private WSH facilities. After 1987 no external support was provided to maintain these provisions. A cross-sectional follow-up survey, which was carried out in 1992, involved about 500 randomly selected households from the intervention and control areas. In 1992 about 82% of the pumps were still in good functional condition and of these, 94% had been functioning well in 1987. Fewer latrines were functional in 1992 (64%) than at the end of 1987 (93%). In the former intervention area about 84% of the adults were using sanitary latrines in 1992 compared with only 7% in the control area. Knowledge related to disease transmission, however, was poor and similar in both areas. People claimed that they used the WSH facilities to improve the quality of their lives. The prevalence of diarrhoeal diseases in the 1992 survey among the control population was about twice that among those in the intervention area.

PIP: This study presents the findings of a 1992 follow-up survey to determine the behavioral and health benefits of the Mirzapur Handpump Project during 1984-92. The project was part of an integrated water supply, sanitation, and hygiene (WSH) education intervention project run by the International Center for Diarrheal Disease Research in Bangladesh. The project was implemented during 1984-87 in five villages in Mirzapur subdistrict among 880 households with 148 improved handpumps, one twin pit latrine for almost every household, and extensive hygiene education. The control area included 750 households with about 42 handpumps. Local women participated in selecting installation sites, maintaining tubewells and latrines, and collecting data. The last program repairs were made in 1987. Findings from the 1992 survey reveal that the percentage of working pumps declined from 100% to 82% during 1987-92. 75% of respondents believed that maintenance was shared by users. The remaining 25% in the intervention area and all in the control area claimed that repair was taken care of by the owners. 84% used tubewell water because of the improved quality. Use of sanitary latrines was the same over time. Use was 83% in the intervention area and only 8% in the control area. There was a decline in the percentage of proper functioning latrines from 98% in 1987 to 64% in 1993. Hygiene practices remained poor in 1993, but still higher than in the control area. Knowledge of the transmission of diarrhea was poor in 1992 and similar in control and intervention areas. Diarrheal morbidity in the previous 24 hours was significantly lower in the intervention area. Findings indicate improvement in health practices but little understanding of WSH practices and improved health. The monitoring measures were useful in determining project sustainability.

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An integrated water supply, sanitation and hygiene (WSH) education intervention project was run by the International Centre for Diarrhoeal Disease Research, Bangladesh, over the period 1983-87. In the intervention area the project provided handpumps, pit latrines, and hygiene education to about 800 households. The control population did not receive any interventions, but had access to the usual government and private WSH facilities. After 1987 no external support was provided to maintain these provisions. A cross-sectional follow-up survey, which was carried out in 1992, involved about 500 randomly selected households from the intervention and control areas. In 1992 about 82% of the pumps were still in good functional condition and of these, 94% had been functioning well in 1987. Fewer latrines were functional in 1992 (64%) than at the end of 1987 (93%). In the former intervention area about 84% of the adults were using sanitary latrines in 1992 compared with only 7% in the control area. Knowledge related to disease transmission, however, was poor and similar in both areas. People claimed that they used the WSH facilities to improve the quality of their lives. The prevalence of diarrhoeal diseases in the 1992 survey among the control population was about twice that among those in the intervention area.

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