Treating Children Without Antibiotics in Primary Healthcare

Narayanan Kutty

Abstract

The overuse of antibiotics in children is becoming a major public health problem. Although most of the common childhood infections such as diarrhea and upper respiratory tract infections are caused by viruses, large volumes of antibiotics are prescribed for these infections in children in the primary care settings. Excessive use of antibiotics is the fundamental risk factor for the development of antibiotic resistance. It is estimated that 90% of upper respiratory tract infections are self limiting viral illnesses and even bacterial infections like acute otitis media often run a self limiting course. Clinical trials have shown that antibiotic use to treat common upper respiratory tract infections like sore throat, nasopharyngitis and otitis media has no or minimal benefit on the clinical outcome. This report discusses two strategies considered to reduce the use of antibiotic in these conditions: i) No prescription, and ii) Delayed prescription of antibiotics for common upper respiratory tract infections. Moreover, this report calls for a significant modification of the prescribing habits of physicians, and to also extend community awareness on the harms of the misuse and overuse of antibiotics. It is imperative to educate health workers as well as the Community in a coordinated and sustainable manner about the growing public health problem of antibiotic resistance.

Immunohistochemical Expression of Estrogen and Progesterone Receptors in Human Colorectal Adenoma and Carcinoma Using Specified Automated Cellular Image Analysis System: A Clinicopathological Study

Ban Jumaa Qasim,¹ Hussam Hasson Ali,² Alaa Ghani Hussein³

Abstract

Objectives: To evaluate the immunohistochemical expression of estrogen receptors (ER) and progesterone receptors (PR) in colorectal adenoma and adenocarcinoma and to correlate this immunohistochemical expression with different clinicopathological parameters.

Methods: The study was retrospectively designed. A total of 86 tissue samples, including 33 paraffin blocks from patients with colorectal adenomas, 33 paraffin blocks from patients with colorectal adenocarcinomas and a control group of 20 samples of non-tumorous colonic tissue, were included in the study.

Results: The frequency of expression of ER and PR showed a gradual increase from control through adenoma to carcinoma. The frequencies of expression of ER in the control, adenoma and carcinoma were (10%, 15.15% and 42.42% respectively, p<0.001), while the frequency of expression for PR were (10%, 24.24% and 36.36% respectively, p<0.001). Strong ER and PR staining was mainly seen in carcinoma cases (42.42%, 36.36%, respectively) in comparison with adenoma (9.09%, 15.15%, respectively) and control (0%, 0%, respectively). The three digital parameters of ER and PR immunohistochemical expression (Area [A], Number of objects [N], and intensity [I]) were significantly increased in a sequence of normal mucosa-adenoma-carcinoma. There was a significant positive correlation between ER and PR in adenoma (r=0.312, p=0.034) and carcinoma (r=0.321, p=0.0398).

Conclusion: ER and PR expression increased in a sequence of; normal colonic mucosa-adenoma-carcinoma, and a positive correlation was observed between ER and PR expression in colonic adenoma and carcinoma specimen indicating that ER and PR may play a role in colorectal carcinogenesis.

Work Related Injuries in an Oil field in Oman

Abstract 

Objectives: The aim of this paper is to describe the epidemiology of occupational injuries in the Harweel oil field, Oman.

Methods: The study is based on data gathered from a computerized database maintained by Petroleum Development of Oman (PDO). All non-fatal work-related occupational injuries registered between April 2007 and December 2009 were gathered and analyzed.

Results: A total of 170 work-related injuries were reported during the study period. Foreign body to the eye was the most common type of injury (27.6%) encountered among all injuries, followed by man falls/slips (11.8%). Injury to the upper extremities accounted for the largest percentage (38.8%) among other body parts. While, a significant portion of the injuries (52%) affected workers aged less than 30 years. The average injury rate per 1000 exposed workers per year was 19.8.

Conclusion: The study outlines the types of injuries most commonly encountered in the oil field in Oman. Additional data is required in order to devise proper epidemiological analysis. Establishing a comprehensive surveillance system for injuries is essential to ascertain factors influencing such injuries.

Shyamapada Mandal,^1* Manisha DebMandal,² Krishnendu Saha,¹ Nishith Kumar Pal¹

Abstract 

Objective: To explore the in vitro antibacterial activity of ethanolic extracts of cinnamon (Cinnamomum zeylanicum; CIN), clove (Syzygium aromaticum, CLV) and cumin (Cuminum cyminum, CMN) against clinical isolates of methicillin resistant Staphylococcus aureus (MRSA), from Kolkata, India.

Methods: The CIN, CLV and CMN were tested for their antibacterial activity against MRSA by in vitro methods. Minimum inhibitory concentration (MIC) values of the three extracts were determined, and time-kill studies were performed in order to investigate the bactericidal activity of the extracts (at the MIC level) for the isolates. The killing efficacy of the extracts was determined at various concentrations.

Results: The zone diameter of inhibition (ZDI) obtained due to CIN, CLV and CMN ranged between 22-27 mm, 19-23 mm and 9-15 mm, respectively; while the MICs, for the isolates, were in the range of 64-256, 64-512 and 128-512 µg/ml, respectively. When tested for their MIC levels; the CIN and CLV were found to be bactericidal after 6 hrs of incubation, while CMN showed bactericidal activity after 24 hrs. However, when tested at various concentrations; CIN, CLV and CMN displayed bactericidal activity against S. aureus, after 24 hrs of incubation, at 200, 200 and 300 µg/ml, respectively.

Conclusion: The C. zeylanicum and S. aromaticum showed the strongest in vitro antibacterial activity followed by C. cyminum against MRSA, and such findings could be considered a valuable support in the treatment of infection and may contribute to the development of potential antimicrobial agents for inclusion in anti- S. aureus regimens.

Satisfaction and Perceived Quality of an Electronic Medical Record System in a Tertiary Hospital in Oman

Abdullah Al-Mujaini,^* Yahya Al-Farsi,^** Abdulla Al-Maniri,^** Anuradha Ganesh^*

Abstract 

Objective: To evaluate the knowledge, attitude and practice (KAP) of physicians towards the Electronic Medical Record (EMR) system.

Methods: A cross-sectional survey including physicians from various clinical specialties was conducted. An existing questionnaire was adapted to assess the KAP of physicians towards the EMR system. Information was analyzed using Statistical Package for Social Sciences (SPSS) software.

Results: Out of 200 distributed questionnaires, 141 (70.5%) responses were received. Overall, only 22 physicians (15.6%) rated the current EMR system as an effective tool. A substantial proportion (29.4%) of respondents considered EMR not worth the time and effort required to use it. The majority (67.4%) reported increasing difficulty with the performance of work after applying the EMR system. The overall quality of work was perceived not to have changed (41.2% of the respondents) or declined (27.4% of the respondents). The low satisfaction and underperformance was found to be associated with younger age (p=0.032), junior designation (p=0.041), and low familiarity with computers (p=0.047).

Conclusion: We report low satisfaction and perceived quality of work among physicians in our institution with the current EMR system. Inappropriate and inadequate usage of the system was found to be the main cause of the underlying poor satisfaction.

Clinical Presentation and Outcome in Hospitalized Patients of 2009 Pandemic Influenza A (H1N1) viral infection in Oman

Akhwand Shakeel Ahmad,¹ Chandrashekar Puttaswamy,² Sayed Mudasser,³ Omaima Abdelaziz³

Abstract

Objectives: In 2009, cases of human infection with a novel influenza A (H1N1) virus were detected and soon reached a pandemic level. Presenting clinical features of this disease in Oman were observed and an attempt was made to identify features predicting the high risk of mortality.

Methods: The clinical and laboratory features at the time of presentation in adult patients admitted with flu-like illness or pneumonia were studied who were later diagnosed as H1N1 infection by PCR of nasopharyngeal and/or throat swabs.

Results: H1N1 infection mostly affected younger individuals who presented with fever and cough. One-third of the patients had rhinorrhea and a few had vomiting and diarrhea. Chest crepitations were common. Most of the patients had normal or low cell counts. The chest X-ray was normal in 23 (41.8%) cases, while in other cases pneumonia was detected characteristically starting from base and extending up. Almost half of the patients were either in frank or impending respiratory failure. Nine (16.4%) patients died.

Conclusion: It is difficult to identify H1N1 influenza cases from other patients with a flu-like illness, but it can be strongly suspected when a patient presents with basal pneumonia, particularly if bilateral, with lymphocytopenia, and is hypoxemic, in the presence of other H1N1 infected cases in the community. These features are also indicative of severe illness with high mortality risk.

Amulets, Bands and Other Traditional Applications seen among Emergency and Neonatal Pediatric Admissions in a Tertiary Centre, Nigeria

Muhammed A.N. Adeboye^1*, Olasunkanmi A. Adegboye¹, Aishatu A. Abdulkarim¹, Edith C. Eze², Mohammed J. Saka³, Abdullahi Usman², Amos Solomon², Bosede F. Rotimi²

Abstract

Objectives: This study aims to investigate the types and indications of amulets, bands and traditional applications among pediatric emergencies and neonatal admissions into the Federal Medical Centre, Bida, Nigeria.

Methods: This was a cross-sectional study conducted between January and July, 2008. Children admitted into the emergency and neonatal units of the institution with traditional applications were recruited. Information on demography, time the application was introduced, the reason, cost implication and belief about the efficacy were obtained using a semi-structured questionnaire. Socio-Economic Class was defined using the Oyedeji Classification.

Results: The study was based at Federal Medical Centre, Bida and consisted of 666 children admitted into the hospital via the Emergency pediatric and the Neonatal Unit, with a seven-month period prevalence of 11.4% (76 patients). Of the 76 cases screened for the use traditional applications, only 64 (84.2%) were recruited, the remaining did not agree to participate in the study. The mean age was 493.1±528.5 days. The study group included 37 males and 27 females (sex ratio 1.4:1) aged 11 days to 2920 days. The applications used included neck band (54.7%), ankle band (15.6%) and head paste (15.6%). Reasons for the applications included prevention of childhood illnesses (17.2%), sutures closure (15.6%), as well as warding off evil spirits and convulsions (12.5%). The socio-economic classification was I (1.6%), II (7.8%), III (15.6%), IV (45.3%), and V (29.7%). Sixty (93.0%) parents believed the applications cannot be used with conventional medicine, while 53.1% of the participants, obtained them free of charge.

Conclusion: The use of traditional applications, often for preventive purposes, is common among pediatric patients, especially of low socio-economic classifications. The majority of users considered them incompatible with simultaneous conventional medical care. This has adverse implications for time to presentation for conventional care and treatment outcomes. Promotive and preventive healthcare interventions are needed to reverse this trend. Future broad-based research is warranted.

Breastfeeding Status and Some Related Factors in Northern Iran

Gholamreza Veghari¹*, Azadreza Mansourian², Aliakbar Abdollahi³

Abstract

Objectives: The main objective of this study is to assess the Breastfeeding Duration, Exclusive Breastfeeding Duration and other related factors among children aged less than 5 years old in rural areas of Northern Iran.

Methods: This is a descriptive cross-sectional conducted on 2520 children aged 6-60 months (male: 1309, female: 1211) chosen by cluster random sampling from 20 out of 118 villages. Data were collected from mothers using a questionnaire. The duration of breastfeeding was computed only for children aged over 24 months old. Breastfeeding duration and Exclusive Breastfeeding Duration were classified based on WHO definition. SPSS Version 16 was used for data analysis.

Results: The mean Exclusive Breastfeeding Duration was 5.59 months, while 66.4% of children had exclusive breastfeeding for at least 6 months. The lowest Exclusive Breastfeeding Duration and the highest Breastfeeding Duration were observed among the Turkman ethnic group. Exclusive Breastfeeding duration of at least 5 months was 14.6%, thus the results were significantly higher than in the Turkman ethnic group (p=0.001). Meanwhile, the results showed that exclusive breastfeeding duration significantly increased with maternal education level (p=0.004). The study found that the mean breastfeeding duration was 20.6 months, and 89.3% and 74.7% of children were breastfed for at least 18 and 24 months, respectively. A positive correlation was reported between breastfeeding duration and family size, birth order, maternal age and children nutritional status, (p<0.05). Additionally, lactation period in underweight children was significantly higher than in obese children, (p=0.023).

Conclusion: The study found that two-thirds of children exclusively breastfed during the first six months of life and the mean breastfeeding duration was 20.6 months. While both exclusive breastfeeding duration and breastfeeding duration were influenced by socio-demographic factors in the rural areas of Northern Iran.

Abstract

Objective: This study aimed to detect the cytomorphological changes in buccal mucosa among alcoholics and cigarette smokers.

Methods: Buccal smears were collected from 200 volunteers; 50 were alcoholics, 50 were cigarette smokers, 50 were alcoholic and cigarette smokers, and another 50 were treated as a control group (neither drinkers nor smokers). The smokers and alcoholics included in this study had been continuously exposed for more than 5 years. Smears were stained using the Papanicolaou technique.

Results: The cytological assessment in the alcoholics group revealed; atypical cellular changes detected in four individuals, bacteria was found in smears of 16 individuals; 18% cocci and 14% actinomyces species were also detected. Hyperkeratosis was detected in five individuals, while 25 individuals showed no oral changes. In the smokers group; atypical cellular changes were seen in six individuals and bacteria were detected in the smears of 15 individuals; 18% cocci and 12% Actinomyces species. Hyperkeratosis was observed in 14% of the individuals, but 44% showed no oral cytological changes. In the cigarette smoking and alcoholics group; atypical cellular changes were detected in only 14%, while bacteria were detected in 54% of smears; 32% were cocci and 16% were Actinomyces species. Changes in cells infected by human papilloma virus were detected in 4% and monilia in 2% of the cases. Also, 20% of the individuals showed hyperkeratosis and 12% showed no lesions.

Conclusion: The study proved that alcohol and cigarette smoking are risk factors for oral atypical cellular changes and possibly of oral infection. The degree of change depends on the duration of alcohol consumption and cigarette smoking.

Transient Osteoporosis of the Hip/Bone Marrow Edema Syndrome with Soft Tissue Involvement: A Case Report

Abstract

Transient osteoporosis of the hip (TOH) is a rare condition mainly affecting pregnant women in their third trimester and middle aged men. We report a case of TOH/Bone marrow edema syndrome in pregnancy with involvement of the surrounding soft tissues on magnetic resonance image, which has not been previously reported. The presence of such edema in the soft tissues may help to differentiate this condition from early avascular necrosis of the hip, and may also provide an insight into the pathogenesis of the condition. The reported patient was treated conservatively and fully recovered.

Late Onset Central Hypoventilation Syndrome due to a Heterozygous Polyalanine Repeat Expansion Mutation in the PHOX2B Gene

Ismail Al Rashdi, Mohammed Al Ghafri, Said Al Hanshi, Nabil Al Macki

Abstract 

This report describes a 6 year old girl with late onset central hypoventilation syndrome due to a heterozygous polyalanine repeat expansion mutation in the PHOX2B gene. This report aims to increase the awareness of this condition among physicians to allow earlier clinical and genetic diagnosis and management of cases of unexplained hypoventilation.

An Uncommon Presentation of Giant Cell Tumor

Hunaina Al-Kindi,¹ Mina George,¹ Gopal Malhotra,² Khamis Al-Muzahmi³

Abstract

Giant Cell Tumors commonly occur at the ends of long bones. However in rare cases, they can occur in the bones of the hands and feet. Tumors in these locations occur in younger patients; in addition, these tumors are more commonly multifocal and are associated with a higher risk for local recurrence than tumors at the ends of long bones. Since lesions in the small bones may be multifocal, a patient with a giant cell tumor of the small bones should undergo a skeletal survey to exclude similar lesions elsewhere. Primary surgical treatment ranges from curettage or excision with or without bone grafting to amputation. The success of surgical treatment depends on the completeness with which the tumor was removed. We are presenting a case report of a 34 year old female, who presented with a swelling in the right hand, following trauma. X-ray of the hand showed an osteolytic expansile lesion at the base of the 1^st metacarpal bone. The lesion was initially curetted and then treated by local resection with bone grafting. Histological examination revealed a typical benign giant cell tumor composed of closely packed stromal cells with a variable admixture of giant cells. Follow up at the end of one year did not reveal any recurrence of the tumor.

Ewing’s Sarcoma Presenting as Pleural Effusion

R.A.S.Kushwaha,¹ Saheer Sainalabdeen,¹ Shipra Anand,¹ Nuzhat Husain²

Abstract 

A 20-year-old female presented to the Pulmonary Medicine Department with complaints of fever, left sided chest pain and progressive dyspnoea of four months duration. Radiological examination revealed a mass lesion with massive pleural effusion and rib erosion. Histopathology showed neoplastic cells with scanty cytoplasm, hyperchromatic nuclei and rosette formation suggestive of Ewing sarcoma. The rarity of this tumor and its unusual presentation prompted this report.

Tricuspid Endocarditis and Septic Pulmonary Embolism in an Intravenous Drug User with advanced HIV Infection

Kadriye Kart Yasar, Filiz Pehlivanoglu,  Sevtap Gursoy, Gonul Sengoz

Abstract 

Cardiac complications are becoming increasingly important in patients with HIV infection. Right-sided endocarditis are more common in intravenous drug users (IVDU) with HIV infection. Some studies have pointed out that the clinical outcome of such patients depends on the affected valve referred to the responsible agent rather than the HIV serostatus. However, severe immunosupression and low CD₄ count are associated with increased risk of death. This report presents a case of isolated tricuspid valve endocarditis with advanced HIV infection who was also an IVDU.

Abstract

Gastrointestinal ganglioneuromatosis is a rare and benign proliferation of both ganglion and Schwann cells, which may present in a variety of clinicopathological characteristics including polypoid, localized and diffuse forms. It is characterized by the presence of a large number of dysplastic ganglion cells or hyperganglionosis. The affected patients are usually children and a number of them have intestinal neuronal dysplasia type B, which may overlap with ganglioneuromatosis. We report a very rare case of gastric ganglioneuromatosis with hyperganglionosis in a 34 year old male, who presented as a case of gastric outlet obstruction and marked gastric dilatation which was diagnosed both clinically and radiologically as a case of gastric obstruction due to gastric malignancy. Based on these findings and because of the patient’s deteriorating clinical situation; the patient underwent distal gastrectomy and the final diagnosis was made following the histopathological examination of the resected specimen. The clinicopathological features and diagnostic criteria of this rare disorder are described together with a literature review of other similar cases affecting different parts of the gastrointestinal tract.

Abstract

Adult-onset Still’s disease (AOSD) is a rare clinical entity with unknown etiology, characterized by arthritis, fever, evanescent rash and other systemic presentations. This report described a 45-year-old male who presented with sore throat, fever, arthritis, evanescent rash, raised liver enzymes and hyperferritinemia. He was diagnosed to have AOSD based on Yamuguchi criteria after the exclusion of other potential diagnoses. The patient partially responded to combined celecoxib and prednisolone. He was also prescribed methotrexate and his symptoms improved.

Abstract

Dermatofibrosarcoma protuberans is a relatively uncommon soft tissue tumor involving the dermal layer of skin with intermediate-to-low grade malignancy. Although metastasis rarely occurs, Dermatofibrosarcoma protuberans is a locally aggressive tumorwith a high recurrence rate. We treated a 35-year-old male patient with Dermatofibrosarcoma protuberans left breast at Pakistan Air Force hospital Karachi. The reluctance on the patient’s side unnecessarily delayed operative procedure. Allowing wide safety margins during resection, an extended resection was carried out. The patient was later subjected to radiotherapy.

Abstract

Solitary rectal ulcer syndrome is common in adults; however, it is thought to be rare in children. The etiology and exact pathogenesis of this condition are poorly understood. The main presenting feature of solitary rectal ulcer syndrome is rectal bleeding, but the clinical diagnosis and treatment remain challenging, particularly in pediatric patients. We present two pediatric patients with solitary rectal ulcer syndrome, who were treated surgically, and remain asymptomatic after the procedures. Clinicians should be aware of this problem in order to avoid delayed diagnosis and management.

Abstract

Splenic artery aneurysm (SAA) is a rare clinical entity that carries the risk of rupture and fatal hemorrhage. Ruptured SAA, especially during pregnancy has fateful consequences for the mother, foetus or both. The role of the Radiologist is very important in preventing mortality. A diagnosis of ruptured SAA should be considered in any pregnant patient who complains of sudden epigastric or upper abdominal pain, with or without shock. This is a report of two cases where the mothers were saved but the foetuses were lost.