Introduction: Necrotizing fasciitis (NF) is a life-threatening infection of soft tissues, requiring prompt diagnosis and an aggressive management. The role of ultrasonography (US) in emergency setting for early diagnosis of NF was reported in literature, its accuracy being estimated 92% both before and without gas production. Presentation of the Case: A 65-year old man, with pulmonary metastasis from colon-rectal cancer, treated with chemotherapy, complained of dyspnoea, fever and a dull pain in his left calf for 3 days. Skin was spared and no evidence of tactile alterations or edema was found. Bedside US focused on the painful zone revealed a small hypo-anechoic area in deep subcutaneous tissue with blurred contours and posterior shadowing (“black-hole sign”), referable to soft tissue necrosis. Thickness and hyperechogenicity of surrounding subcutaneous tissue, due to diffuse inflammatory infiltrate and edema, and thin distal fluid collection along the fascia, were also detected, without gas artifacts. Surgery debridement was performed, tissue cultures yielding Escherichia Coli, maybe due to the disruption of bowel mucosal wall. Discussion and Conclusion: Bedside goal-directed US performed by emergency physician can exclude alternative aetiologies to NF in severe localized pain of the lower extremity. The depiction of blurred focal changes in the soft tissue, configuring an US “black-hole sign” and referable to fat necrosis and suppurative infiltration, may represent the main early finding of NF, especially in the idiopathic form. Its identification should alarm physicians, inducing further investigations and close monitoring. The employment of bedside goal-directed US should be stressed in Emergency Department.
Introductions: Cognitive models of social anxiety disorder (SAD), such as that developed by Clark & Wells, conceptualize the attention to, and misinterpretation of, internal information as a key maintaining factor. Social skills training (SST), a frequently used cognitive therapy (CT) technique for various mental disorders, is often justified according to a skills-deficit model of SAD, which assumes that anxiety arises from inadequate social interaction skills. However, the evidence largely suggests little to no skills deficit in this patient group, indicating that SST is not necessarily a technique to be used in CT for most SAD patients. In this study, we present a patient with SAD who negatively perceived her social skills abilities, and who benefitted from SST. We also discuss the role of brief SST in CT treatment. Presentation of Case: The patient was a Japanese female with excessive fear of social interactions who negatively perceived her own social skills. Cognitive therapy mainly consisted of case formulation, behavioral experiments, and opinion surveying based on the Clark & Wells model. As the patient felt too anxious to attempt behavioral experiments, due to her negative perception of her own social skills, SST was briefly employed in the course of CT. Discussion and Conclusion: As the patient’s actual social skills abilities were never formally assessed, it is impossible to know if she had any social skills deficits prior to treatment, and, if so, if they were improved by the SST provided. However, SST encouraged the patient to try challenging tasks, notably behavioral experiments and homework centering on feared social situations. Although SST should not necessarily be included in CT for SAD patients, SST can help patients to decrease their excessive fear of being negatively perceived due to poor social skills, making it easier for them to try challenging behavioral experiments in feared social situations.
Aims: To identify the frequency of meconium aspiration syndrome among the total births who suffered from meconium staining of amniotic fluid, to find out risk factors during pregnancy, therapies and various complications associated with this condition and their effects on perinatal outcome. Study Design: Retrospective study. Place and Duration of Study: AL-Yarmouk Teaching Hospital, between 1st of December 2009 to 31st of May 2010. Methodology: Total number of live birth deliveries was 5965, live births with meconium staining of amniotic fluid were 286 and meconium aspiration syndrome cases were 13. Collection of information included gestational age, fetal presentation, mode of delivery, birth weight, sex, Apgar score, type of resuscitation, treatment, associated complications and outcome. Inclusion criteria for meconium staining of amniotic fluid cases were; gestational age of ≥30 wk, presence of meconium stained skin, umbilical cord or meconium in the trachea at birth. Results: Total number of live birth deliveries matching criteria of inclusion in the study was 5965. Of these, 286 (4.8%) cases had meconium stained amniotic fluid which included 13 (4.5% of MASF cases, 0.21% or total live births) cases of meconium aspiration syndrome. Babies who were term or normal for gestational age were more prone to meconium aspiration syndrome and meconium stained amniotic fluid (P = .0008 and .016, respectively). Emergency cesarean section was significantly associated with a decreased rate of meconium stained amniotic fluid cases (P .0001). Thick meconium was more risky than thin (P = .0009). Three neonates died due to meconium aspiration syndrome complicated by respiratory failure and pneumothorax. Mortality was 23.1% of total meconium aspiration syndrome cases and 1.04% of total meconium stain amniotic fluid cases. Conclusion: Babies at highest risk of meconium aspiration syndrome and meconium stained amniotic fluid were those who had completed their term and who had an appropriate birth weight for their gestational age. Moreover, Thick meconium is associated with low Apgar scores and higher morbidity than thin meconium. Finally, abnormal presentation is an important risk factor for MAS, whereas emergency cesarean section is significantly associated with a decreased rate of meconium stained amniotic fluid cases.
Re-transplantation operation is a technically difficult procedure because of many adhesions; it has higher morbidity and mortality. In this article a maneuver facilitating liver re-transplantation is described. 27-year old male with hepatic artery thrombosis three months after the deceased liver transplantation admitted to our clinic for re-transplantation. Related living right lobe liver transplantation was planned. During recipient’s hepatectomy, the hepatic hilum was transected first, but retroperitoneal dissection and identification of the patient’s vena cava was very difficult. Prolonged operative time and risk of mesenteric venous hypertension after the clamping of portal vein required an application of temporary porto-caval bypass. For this shunt the portal vein of recipient and lower end of cadaveric liver vena cava (“piggyback vena cava”) were used. Vena cava of patient was not clamped during the bypass application, so blood flow in patient’s inferior vena cava was not deteriorated. The liver was removed with both caval veins (cadaveric liver vein and recipient’s own vein) remained in patient’s body. Living donor graft was connected to the piggyback vena cava. Temporary shunt was divided and portal vein anastomosed to the graft portal vein. Arterial anastomosis was performed with recipient’s gastroepiploic artery and the biliary reconstruction fashioned by Roux-en-Y hepaticojejunostomy. So, piggyback vena cava can be used successfully and safely for temporary porto-caval shunt during the liver re-transplantation.
Aims: Recent studies have shown independently inter-correlations between allergy, obesity, leptin hormone, and stress markers. However, these findings were unclear and contradictory. Thus the aim of the present study is to evaluate diurnal levels of salivary cortisol and DHEA in sample of Jordanian young men with history of olive pollen-induced allergic rhinitis in relation to serum levels of leptin. Methodology: 130 university male students aged (21.98±1.78) years, were divided into two groups (59 allergic and 71 non allergic). Fasting blood samples were collected and tested for blood glucose, lipid profile, serum leptin, and salivary stress hormones (cortisol and DHEA). Results: Allergic subjects showed significantly higher means of serum leptin (p<0.0001), LDL (p<0.0001), Total cholesterol (p=0.001), and BMI (p= 0.004). Also BMI and Body weight significantly correlated with serum leptin in all subjects of the study. Stronger correlation was observed in allergic subjects (r = 0.650; r = 0.589) compared with non allergic subjects (r = 0.349; r = 0.383) respectively. Simple linear regression analysis showed that morning salivary cortisol ( p=0.006) and midnight salivary DHEA ( p=0.015 ), were significantly correlated in allergic subjects with the serum leptin levels concentration. Conclusion: These results revealed an association between the morning salivary cortisol and elevated serum leptin levels in Jordanian young men with olive pollen induced allergic rhinitis.
Aims: Our study was undertaken to examine the laboratory and clinical features of pernicious anemia patients presenting initially at the Turgut Ozal Medical Center, which serves as an important tertiary health center in Eastern Anatolia. Study Design: Among patients evaluated for etiology of anemia, we analysed the clinicopathological characteristics of 300 (158 females and 142 males) patients with pernicious anemia retrospectively. Place and Duration of Study: Department of Internal Medicine and Division of Hematology, Inonu University School of Medicine, between 1996 and July 2011. Methodology: Full blood counts, thyroid hormone levels, liver function tests and LDH levels were reviewed for 300 patients with pernicious anemia retrospectively. Peripheral blood smears and bone marrow biopsies were reviewed by a hematologist. Endoscopic examination and ultrasonographic inspection were performed for atrophic gastritis, gallbladder stones and hepatosplenomegaly for all patients. Laboratory values, ages, signs and symptoms of patients at the time of diagnosis were compared between genders. Results: The mean age of the female patients was 50.56 ± 17.75 years (17–84), while that of the male patients was 57.24 ± 15.78 (20–95) years. At the time of diagnosis, the male patients were older than the females (p = 0.002). LDH levels were significantly higher for females (p = 0.043). The incidence of gallstones was significantly higher in females (25.4%) than in males (10.7%) (p = 0,001). Pancytopenia was defined as a hemoglobin level lower than 10 gr/dl, leukocytes lower than 1.500/µL and platelets lower than 150.000/µL and the incidence of pancytopenia was 41.3% (n = 65) and 50.7% (n = 71) in the female and male patients, respectively, and the difference was not statistically significant. There was no statistically significant difference for frequency of thyroid disease or symptoms and signs at the time of diagnosis between genders. Conclusions: Pernicious anemia is not a disease of only elderly women; it can be seen in both men and women of younger ages. It is seen nearly as often in women as in men. Gallstones and abnormal thyroid activity can be observed at these patients at the time of diagnosis; therefore, these findings should be considered.
Aim: Waterpipe smoking is becoming increasingly popular in the U.S., especially among minority groups. The purpose of this preliminary study was to explore the patterns of waterpipe use, as well as the association between acculturation factors and waterpipe use among Arab immigrants living in the Richmond, Virginia (VA) metropolitan area. Methods: We surveyed self-identified Arab American Immigrants in Middle Eastern restaurants/lounges and Middle Eastern groceries, in the Richmond, VA metropolitan area. A total of 221 Arab Americans participated in this study. Results: In this sample, higher rates of waterpipe use were found among male subjects (66.6%) than females (31.4%).Our results indicated no significant association between the type of tobacco used (exclusive versus dual) and desire or future intentions to quit waterpipe use. Upon examining the proxy indicators of acculturation, none of them was significant for the entire sample. However, upon stratifying the results by group (exclusive vs. dual), exclusive waterpipe use was significantly correlated with proportion of life lived in the US as r(16)=0.56, p=0.02 but the correlation remained not significant among dual smokers r( 23)= 0.08, p=0.6. Conclusion: Further studies are needed to confirm the relatively high prevalence of waterpipe use among Arab Americans. There is a need to develop effective prevention strategies that will consider the acculturation process when trying to control the spread of waterpipe use among minority groups in the U.S.
The aim of this study was to vaccinate layer hen chickens against Salmonella infection. Two vaccines were assessed for efficacy and safety: a DNA vaccine containing Salmonella genomic DNA encapsulated in a liposome as a vector and a live attenuated Salmonella vaccine comprising 5 attenuated Salmonella serovars that were attenuated using indigenous plant extracts such as garlic and onion. The results showed that both vaccines had a high protection capacity, preventing Salmonella infection after challenge with a wild type of SalmonellaTyphimurium. Hyper-immune eggs inhibited the growth of Salmonella spp in vitro in immunized chickens. ELISA demonstrated the specific antibody production to LPS of S. Typhimurium. Post-mortem studies confirmed the presence of salmonellosis in the control group but not in immunized chickens with either vaccine. This study shows that Poultry salmonellosis can be prevented by the use of prophylactic DNA or live-attenuated vaccines (LAV).
Aim: To determine the pattern of bone metastasis in breast cancer patients. Study Design: Retrospective case series Place and Duration of Study: Data were collected at Eko Hospital radiotherapy facility, Lagos, Nigeria, between years 2006 and 2011. Methodology: A total of 67 patients with a histologically confirmed diagnosis of breast cancer from 2006 to 2011 treated at a radiotherapy facility were analysed to describe the pattern of bone metastasis. Radiological imaging included chest X-ray, X-rays of the bone, bone scan, and Computed Tomography scan (CT scan). Result: Of the 67 eligible breast cancer patients, one is male and 66 are female. The average age of the patients was 46 years old, ranging from 28 to 77 year old. Among the 67 patients who received radiotherapy, 58 (87%) have bone metastases. The most common sites of bone metastases are spine (61%), pelvis (22%), and long bones (22%). Among the 32 patients without metastasis at presentation, the median duration from diagnosis to onset of symptoms of bone metastasis was 16.5 months, ranging from 5 to 38 months. Thirty-one patients had osteoblastic lesions, 24 patients had osteolytic lesions, and 2 patients had mixed osteolytic and osteoblastic lesions. Conclusion: Bone metastasis remains common and incurable. Early recognition and better description of bone relapse patterns of metastatic breast disease will allow rapid administration of effective palliative treatment.
Aims: Our aim was to assess the prevalence of diabetes mellitus through self-reports and measurement of fasting glucose level in a representative sample of Albanian adults residing in Tirana. Study Design: Cross-sectional study. Place and Duration of Study: The survey was conducted in urban Tirana during April-July 2012. Methods: A population-based sample of 795 individuals aged ≥18 years was included in this study (60% women; overall mean age: 50.3±18.7 years; response rate: 79.5%). Finger stick method was used to measure fasting glucose level in all participants. Furthermore, weight and height were measured. Data on socio-demographic and socioeconomic factors were also collected. General linear model was used to assess the association of mean glucose level with demographic and socioeconomic characteristics and anthropometric indices. Results: The overall prevalence of self-reported diabetes was 11.8%. In multivariable-adjusted analysis, among non-diabetic individuals, age and body mass index were significantly and positively associated with mean fasting glucose levels. Conversely, among diabetic individuals, no statistically significant differences of mean glucose levels were observed upon multivariable-adjustment. Conclusions: The prevalence of diabetes mellitus in this representative sample of primary health care users in Tirana was higher than previous reports from Albania. The management and control of diabetes is not adequate in the Albanian primary health care system, exposing individuals to a high risk for future diabetic complications.
Aim: The main aim of this study was to determine the prevalence of diabetes mellitus in patients with active pulmonary tuberculosis at the University of Gondar Teaching Referral Hospital, northwest Ethiopia. Study Design: A cross-sectional hospital-based study was performed using the WHO structured diabetic assessment protocol. Place and Duration: The study included all active pulmonary tuberculosis patients visiting the University of Gondar Teaching Referral Hospital during the study period (October 2011 to November, 2012). Methodology: We included 199 consecutive active pulmonary tuberculosis patients; 117 of these were male and 108 were urban dwellers. Analyses of fasting blood glucose level were carried out using blood samples collected by finger puncture. For testing significance, categorical data were compared using a chi-square test and expressed as proportion with a 95% confidence interval. Result: The prevalence of diabetes was found to be 8.5 % [95%CI: 4.6– 12.5], which was higher (11.1%) among male than female participants (4.9%). Likewise, 10.2% of the patients were from urban and 6.6% from rural areas. The proportion of newly diagnosed diabetic cases was 52.9%, and all of them were between 25-44 years of age. The Prevalence of impaired fasting glucose was 29.6%. The prevalence of HIV co-infection in the study population was 28.6% [95%CI: 22.3 34.9] and Diabetes was 4 times higher among HIV co-infected patients than among HIV-negative tuberculosis patients. Of all patients with active tuberculosis, 146 (73.7%) were sputum smear negative for acid fast bacilli. The proportion of diabetes was 9.6% among smear positive and 8.2% among smear negative cases. Conclusion: The prevalence of diabetes mellitus and pre-diabetes among active pulmonary tuberculosis cases was higher compared to the published prevalence of DM in the general population. Therefore, it is important to implement an active case detection of diabetes among tuberculosis patients.
Aim of the Study: Thrombosis is rare in childhood with limited studies. Our retrospective study was designed to evaluate children with documented thrombotic events registered in our pediatric hematology -oncology unit over the last 3 years as regards clinical features, etiology, management and outcomes. Methods: Among 963 newly registered, 30 patients (16 females and 14 males, median age 4.5 years) with clinical and radiological evidence of thrombosis were identified. Data collection included clinical presentation, identifiable risk factors, thrombophilia screening, radiologic investigations, treatment and outcome. Results: Age at first thrombotic event was higher for patients with secondary than primary etiology (p=0.018). In 66.7% of patients, there was at least one identified risk for thrombosis, and cancer chemotherapy was the most frequent etiology. Inherited thrombophilia were proven in 13.3%. Secondary thrombophilia presented mostly with neurological symptoms (70%) while inherited thrombophilias with purpura fulminans (80%) (p=0.001). The recurrence was higher with primary (30%) compared to secondary thrombophilias (10%). Patients' outcome included neurologic deficit (26.7%), recurrence (16.7%), amputation (6.7%) and death (16.7%). Conclusion: Thrombosis secondary to an acquired risk factor occurred at older age, commonly presented by central thrombosis with no significant difference between primary and secondary thrombosis in the residual effects. Further studies are warranted to determine proper duration of anticoagulant therapy to prevent recurrence.
Aims: This study aims to investigate the effect of cytomegalovirus (CMV) and diabetes mellitus (DM) on the cell-mediated immunity against TB represented by cytokine profile Study Design: Case control study. Place and Duration of Study: This study was carried out in Specialized Chest and Respiratory Center in Baghdad, Iraq and Department of Medical Microbiology-College of Medicine -Babylon university Hilla-Iraq, the period of study was October 2012 to January 2013. Methodology: This study was applied on 70 TB patients .It involved also 30 apparently healthy control. The patients consists of 43 males and 27 females with age range 8-76 years old, 29 of them were diabetic .Blood samples were collected from patients and controls to estimate the immune parameters interferon-gamma (IFN-γ) and interleukin -2(IL-2 )as , and anti –CMV IgG antibodies by enzyme linked immunosorbent assay (ELISA). Results: The immune parameters showed that there is no significant difference in the mean serum concentration between the patients and control groups for IFN-γ and IL-2 (P=0.05), while there was a significant increase in the mean serum concentration of anti-CMV IgG between study groups (P≤0.001). The study also showed that there is a significant decrease in the mean serum concentration of IL-2 and IFN-γ between diabetic TB patients comparing with those non-diabetic TB patients where p values were 0.008 and 0.024 respectively. Conclusion: Both CMV and diabetes mellitus have a role in the suppression of cellular immunity in TB patients.
Background: Polycystic ovary syndrome (PCOS) is a complex, heterogeneous disorder of uncertain etiology, characterized by irregular menses, chronic anovulation, infertility, hyperandrogenism, and insulin resistance. Aims: To determine insulin resistance in infertile Sudanese patients with PCOS and evaluate its significant relation ship to infertility. Method: A hospital based transversal study was conducted at the Minimal Access Gynecology Surgery (MAGS) unit at Omdurman Maternity Hospital from June 2010 to August 2012 .61 infertile patients with PCOS using Rotterdam 2003 definition and who did not conceive after diet, lifestyle and clomiphene as study group and 61 normo-ovulatory infertile patients with normal ovaries served as a control group at laparoscopy, their serum were sent to the laboratory for estimation of fasting glucose and insulin levels, and then calculation of homeostatic model assessment (HOMA) and p value.
Results: 44(73%) out of the 61infertile patients with PCOS were young, obese with BMI>30, hirsutism was seen in 45 (73.5%) and acne was observed in 42 (70%). Fasting blood glucose (FBG) of 100-125 mg/dl, was encountered in 18(30%) and 3 were diabetic (FBG >125). Fasting insulin level was not significantly elevated in the study group, while Insulin resistance calculated using HOMA. Mean HOMA in the obese PCOS group was significantly higher than in the obese normal ovary group (2.68 ± 2.19 versus 1.26 ± 1.05, P = 0.005). Conclusion: The majority of the study population was young, obese and had insulin resistance This finding may have important implications in the short term regarding reproductive performance, and in the long term regarding type 2 diabetes and cardiovascular complications
We selected the pediatric urinary tract infection related research and review articles in English language using keywords or phrases such as Infant; children; culture; Escherichia coli; fever, UTI. Aims: The purpose of this review is to provide summary of the latest research in particular to the practical aspects of management of UTI in children. Background: Urinary tract infection (UTI) is an important medical entity commonly diagnosed during early childhood. Prevalence and incidence of UTI varies with age and gender. UTI can be missed just on history and clinical examination. Screening of UTI in high risk children is important and should be well balanced against cost and risk of missing UTI. Despite latest evidence from research there are still controversies in managing UTI in children. Conclusion: Despite major advances in management of UTI in neonates and children, uniform guidelines for the imaging and management of recurrent UTI are lacking, prompting a multinational large research project to fill in the knowledge gap.