Environmental health services (EHS) in healthcare facilities (HCFs) are critical for safe care provision, yet their availability in low- and middle-income countries is low. A poor understanding of costs hinders progress towards adequate provision. Methods are inconsistent and poorly documented in costing literature, suggesting opportunities to improve evidence. The goal of this research was to develop a model to guide budgeting for EHS in HCFs. Based on 47 studies selected through a systematic review, we identified discrete budgeting steps, developed codes to define each step, and ordered steps into a model. We identified good practices based on a review of additional selected guidelines for costing EHS and HCFs. Our model comprises ten steps in three phases: planning, data collection, and synthesis. Costing-stakeholders define the costing purpose, relevant EHS, and cost scope; assess the EHS delivery context; develop a costing plan; and identify data sources (planning). Stakeholders then execute their costing plan and evaluate the data quality (data collection). Finally, stakeholders calculate costs and disseminate findings (synthesis). We present three hypothetical costing examples and discuss good practices, including using costing frameworks, selecting appropriate indicators to measure the quantity and quality of EHS, and iterating planning and data collection to select appropriate costing approaches and identify data gaps.

Collagen and calcium-binding EGF domain-containing protein 1 (CCBE1) bi-allelic mutations have been associated with syndromes of widespread congenital lymphatic dysplasia, including Hennekam Syndrome (HS). HS is characterized by lymphedema, lymphangiectasia, and intellectual disability. CCBE1 encodes a putative extracellular matrix protein but the HS-causing mutations have not been studied biochemically. We report two HS siblings, born to consanguineous parents of Turkish ancestry, whose clinical phenotype also includes protein losing enteropathy, painful relapsing chylous ascites, and hypogammaglobulinemia. We identified by whole exome and Sanger sequencing the homozygous CCBE1 C174Y mutation in both siblings. This mutation had been previously reported in another HS kindred from the Netherlands. In over-expression studies, we found increased intracellular expression of all forms (monomers, dimers, trimers) of the CCBE1 C174Y mutant protein, by Western blot, despite mutant mRNA levels similar to wild-type (WT). In addition, we detected increased secretion of the mutant CCBE1 protein by ELISA. We further found the mutant and WT proteins to be evenly distributed in the cytoplasm, by immunofluorescence and confocal microscopy. Finally, we found a strong decrease of lymphatic vessels, with a corresponding diminished expression of CCBE1, by immunohistochemistry of the patients’ intestinal biopsies. In contrast, mucosal blood vessels and muscularis mucosae showed normal CCBE1 staining. Our findings show that the mutant CCBE1 C174Y protein is not loss-of-function by loss-of-expression.

The aim of this preliminary study was to identify key behavioural indicators of pain in cats. The behaviour of cats before and after ovariohysterectomy was analysed using a detailed behavioural ethogram. A comparison of behaviours between cats given pre-operative analgesia only and cats given both pre- and post-operative analgesia indicated that both groups demonstrated changed behaviour following surgery, compared to a control group of cats which underwent anaesthesia but not surgery. However, some specific postures, such as ‘half-tucked-up’ and ‘crouching’, were identified that occurred with greater frequency in the cats receiving pre-operative analgesia only, as compared to those receiving additional post-operative analgesia. This indicates that there are some key behaviours that may be useful in determining pain in cats. Routine administration of pre- but not post-operative analgesia may be ineffective for adequately alleviating pain in cats.

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Sir: As a longstanding member of ISPO, I would like to express my concern over the animal welfare in the experiments of M. Akai et al. as reported in their paper 'A computer-controlled contracture correction device with low-load and continuous torque: An animal experiment and prototype design for clinical use' in the June 2007 issue of Prosthetics and Orthotics International.The experiment involved surgery to the rats to induce a flexion contracture, multiple anaesthesia and stretches to one group, and the suspending of rats with rear legs raised for 5 -7 days with a constant torque device attached in a second group.During the first part of the experiment, 35% of the rats were excluded from the study due to death (17%), infection/fracture (15%) and insufficient weight gain (3%). During the second part of the study, 19% were excluded due to insufficient weight gain with or without an infectious abscess. The high exclusion rate suggests a high level of suffering for these creatures.The authors state that they were unable to confirm whether or not the animals felt pain during the application of extension torque and how much physical burden was caused and that this is an unavoidable problem when using an animal model to mimic the clinical situation.The conclusion of the study was that low load and continuous torque was found to be effective in correcting joint contracture. This confirms what is already widely accepted and thus little new information has been learnt. The design of a new contracture device for clinical use could have been done, I believe without this animal experiment.By publishing such a paper, I believe that ISPO is endorsing this experiment which has questionable animal welfare safeguards and indeed is probably not necessary in the first instance. Lucy BestProsthetist and orthotist locum, UK Prosthetics and Orthotics International December 2007; 31(4): 405