Liquid Ventilation

Zahra Razavi, Mehran Ahmadi

Abstract

Objectives: To improve glycemic control and prevent late complications, the patient and diabetes team need to adjust insulin therapy. The aim of this study is to evaluate the efficacy of thrice-daily versus twice-daily insulin regimens on HbA1c for type 1 diabetes mellitus by a randomized controlled trial in Hamedan, west of Iran.

Methods: The study included 125 patients under 19 years of age with type 1 diabetes mellitus over a 3-month period. All patients with glycohemoglobin (HbA1c) ³8% were followed prospectively and randomized into two trial and control groups. The control group received conventional two insulin injections per day: a mixture of short-acting (regular) + intermediated acting (NPH) insulins pre-breakfast (twice daily), and the trial group was treated by an extra dose of regular insulin before lunch (three times daily). Main outcome measure was HbA1c at baseline and at the end of 3 months. The mean blood glucose level and number of hypoglycemia were recorded. All patients underwent monthly intervals follow up for assessing their home blood glucose records and insulin adjustment.

Results: Overall, 100 patients completed the study protocol. 52% were females, mean ±SD of age of 12.91 ± 3.9 years. There were no significant differences in baseline characteristics including age, gender, pubertal stage, adherence to diet, duration of disease and total daily insulin dose (p>0.05). There was a significant decrease individually in both groups in HbA1c level (p<0.05), but there was no significant difference in HbA1c reduction in patients on twice-daily insulin injections and those on thrice-daily insulin injection groups (1.12 ± 2.12 and 0.98±2.1% respectively, p>0.05).

Bronchial Anthracosis: A Potent Clue for Diagnosis of Pulmonary Tuberculosis

Mostafa Ghanei, Jafar Aslani, Mohammadreza Peyman, Masoud A. Asl, Omidreza Pirnazar

Abstract

Objectives: Occupational exposure to carbon, silica, and quartz particles are predisposing factors for bronchial anthracosis. In some cases anthracosis may be associated with mycobacterium tuberculosis. This study aims to investigate the clinical, radiographic, and bacteriologic findings in bronchial anthracosis patients and its association with tuberculosis.

Methods: This is a prospective study conducted between 1998 and 2001. A total of 919 patients underwent diagnostic bronchoscopy for pulmonary diseases. Of these, 71 patients showed evidence of bronchial anthracosis, 32 (45.8%) males and 39 (54.2%) females, age range, 30-92 years. The distinctive clinical features, nature of bronchoscopic lesions, and radiologic findings were analyzed prospectively and summarized. Bacteriologic studies and results of laboratory examinations were also assessed.

Results: Forty-one (57.8%) patients had positive smears or cultures for mycobacterium tuberculosis. Of 71 patients with bronchoscopic evidence of pulmonary diseases, 30 had previous occupational exposure, and 41 stated no previous exposure. Cavitary lesions on chest radiography, positive purified protein derivative tests and high ESR were more prevalent in tuberculous patients than the others.

Conclusion: Bronchial anthracosis was caused by active or previous tuberculous infection. Detailed examinations for the presence of active tuberculosis should be performed in patients with such bronchoscopic findings in order to prevent the spread of tuberculosis and to avoid unnecessary invasive procedures.

The Awareness and Prevalence of Metabolic Syndrome in Medical Community of Bahawalpur

Mazhar Faiz Alam,¹ Saima Nasreen,¹ Ehsan Ullah,² Anila Hussain³

Abstract

Objectives: We investigated the frequency of Metabolic Syndrome and evaluated the level of awareness about this condition in medical community (healthcare workers) of Bahawalpur, Pakistan.

Methods: It was a cross-sectional study. It was carried out over a period of one year (June 2008 to May 2009). The following institutions took part in the study: Bahawal Victoria Hospital, Quaid-e-Azam Medical College, Paramedical and Nursing Schools and Female Jubilee Hospital. A total of one hundred and ninety four (194) Doctors and Paramedics (Nurses and Dispensors) working in the institutions included in study were selected by simple random sampling technique. Demographic, anthropometric, and biochemical data were recorded, lifestyle features were inquired about, and the level of awareness regarding MetS was surveyed. The criteria recommended by the Adult Treatment Panel (ATP) III were used for the diagnosis of MetS. The presence of MetS was evaluated in all (194) subjects.

Results: Metabolic syndrome was diagnosed in 29 participants (14.95%), and there was no statistically significant difference between men and women in this respectAt least three criteria of MetS were correctly listed by 36 participants (18.56%), with physicians showing significantly higher awareness levels (p<0.001). The frequency of abdominal obesity was 22.68% and it was significantly higher in males than in females (29.29% vs 14.74%; p<0.001).

Conclusion: Current study shows that only a minority of medical community are aware of MetS as a clinical entity. Nurses and other paramedics are unaware of the problem.

Attitudes Towards Informed Consent: A Comparison Between Surgeons Working in Saudi Arabia and the United Kingdom

Bakur A. Jamjoom,¹ Aimun A.B. Jamjoom,¹ Momen Sharab,² Abdulhakim B. Jamjoom²

Abstract

Objectives: Changes in legal standing and new guidelines for consent have generated changes in medical culture that doctors must adhere to. This study aims to highlight the differences in the way the surgeons in the two cultures view the informed consent for surgery processes.

Methods: The attitudes towards informed consent of a group of surgeons working in Saudi Arabia (KSA) were compared with those of a similar group working in the United Kingdom (UK), a country with a longer medical history and a more established medico-legal system.

Results: The study shows that KSA surgeons tend to view informed consent not only as an ethical and legal obligation but also as a benefit to patients. In addition, KSA surgeons are more likely to adopt a paternalistic attitude during informed consent. They believe that information about harmful risks may dissuade their patients from undergoing the operation and they admit that the amount of information they provide to their patients is significantly influenced by a number of patient and non-patient related factors.

Conclusion: It is concluded that surgeons in KSA should be more aware of the informed consent guidelines and they should adhere to them. In addition, there is room for the introduction of formal training on informed consent in both countries and for making written information more widely available particularly in KSA.

Recurrent Laryngeal Nerve Injury in Thyroid Surgery

Hazem M. Zakaria,1 Naif A. Al Awad,1 Ali S. Al Kreedes,1 Abdul Mohsin A. Al-Mulhim,1 Mohammed A. Al-Sharway,1 

Maha Abdul Hadi,1 Ahmed A. Al Sayyah2

Abstract

Objectives: Vocal cord paresis or paralysis due to iatrogenic injury of the recurrent laryngeal nerve (RLNI) is one of the main problems in thyroid surgery. Although many procedures have been introduced to prevent the nerve injury, still the incidence of recurrent laryngeal nerve palsy varies between 1.5-14%. The aim of the present study is to assess the risk factors of recurrent laryngeal nerve injury during thyroid surgery.

Methods: Patients who had thyroid surgery between 1990 and 2005 and were admitted to the surgical department of King Fahd hospital of the University, Al-Khobar, Saudi Arabia were enrolled for this retrospective review, Factors predisposing to recurrent laryngeal nerve injury were evaluated such as pathology of the lesions and the type of operations and identification of recurrent laryngeal nerve intra-operatively. Preoperative and postoperative indirect laryngoscopic examinations were performed for all patients.

Results: 340 patients were included in this study. Transient unilateral vocal cord problems occurred in 11 (3.2%) cases, and in 1 (0.3%) case, it became permanent (post Rt. Hemithyroidectomy). Bilateral vocal cord problems occurred in 2 cases (0.58%), but none became permanent. There were significant increases in the incidence of recurrent laryngeal nerve injury in secondary operation (21.7% in secondary vs. 2.8% in primary, p=0.001), total/near total thyroidectomy (7.2% in total vs. 1.9% in subtotal, p=0.024), non-identification of RLN during surgery (7.6% in non-identification vs. 2.6% in identification, p=0.039) and in malignant disease (12.8% in malignant vs. 2.9% in benign, p=0.004). However, there was no significant difference in the incidence of recurrent laryngeal nerve injury with regards to gender (4.1% in male vs 3.8% in female, p=0.849).

Conclusion: The present study showed that thyroid carcinoma, re-operation for recurrent goiter, non-identification of RLN and total thyroidectomy were associated with a significantly increased risk of operative recurrent laryngeal nerve injury.

Retrospective Review of Cross Sectional Imaging Findings of Pancreatic Non-functional Islet Cell Tumor (NFICT) and its Hepatic Metastases

Rashid AL Sukaiti,¹ Kathryn Robinson,² Christine Menias²

Abstract

Objectives: Review and correlate the computed tomography (CT) imaging features of pancreatic Non Functional Islet Cell Tumors (NFICT) and its hepatic metastases.

Methods: CT examinations of 28 patients with pathologically proven diagnosis of pancreatic NFICT and no clinical symptoms or signs attributed to hormone overproduction, performed at Mallinkrodt Institute of Radiology, Saint Louis, Missouri, USA between March 2002-July 2006, were retrospectively reviewed by two abdominal radiologists. The imaging findings were analyzed and summarized.

Results: Pancreatic NFICT size ranged from 1.2-13 cm. The commonest pattern of enhancement was hypervascular and heterogenous enhancement. The spleen was the commonest invaded nearby local structure. The commonest pattern of enhancement noted in the metastatic liver lesions was hypervascular heterogenous enhancement. 26% of the liver metastatic lesions were associated with invasion/encasement of nearby vessels.

Conclusion: Imaging features of pancreatic NFICT can overlap with other pancreatic neoplasms. Therefore combining the imaging features of pancreatic NFICT and its hepatic metastases helps in narrowing the differential diagnosis.

Serotype Prevalence and Penicillin-susceptibility of Streptococcus pneumoniae in Oman

Mubarak M. Al-Yaqoubi,¹ Kamal M. Elhag²

Abstract

Objectives: to determine the prevalent serotypes of Streptococcus pneumoniae and the rate of penicillin-nonsusceptibility among pneumococci in Oman.

Methods: Pneumococcal isolates encountered during the period of September 2002 to December 2007 in the Royal Hospital were serotyped. Clinical information as well as the penicillin susceptibility reports were retrieved from the hospital information system and medical records.

Results: 120 strains of Streptococcus pneumoniae were isolated of which 85 strains were seroptyped. 20 different serotypes were identified; the most common seroptypes were 9A, 6B, 19F, 14 and 23F. 56% of the strains were not susceptible to pencillin, while 99% of these were susceptible to ceftriaxone. 74.3% and 46.1% of the serotypes are covered by the pneumococcal polysaccharide vaccine and the 7-valent pneumococcal conjugate vaccine respectively.

Conclusion: Certain few pneumococcal serotypes such as 9A, 6B and 19F are more prevalent in the Omani community than others. More than half of S. pneumoniae are not susceptible to penicillin while the great majority of the strains are susceptible to ceftriaxone.

Effect of Tropicamide and Homatropine Eye Drops on A-Scan Parameters of the Phakic Normal Eyes

Jagdish Bhatia

Abstract

Objectives: A prospective study to evaluate the changes in A-Scan axial parameters of phakic normal eyes before and after instillation of 1% topical Tropicamide and 2% Homatropine eye drops.

Methods: Anterior chamber depth, lens thickness, vitreous chamber length, and ocular axial length were measured in 76 eyes before and after cycloplegia induced by 1% topical Tropicamide, and in 28 eyes with 2% Homatropine eye drops.

Results: Anterior chamber depth demonstrated increase from baseline readings with Tropicamide and Homatropine eye drops, while lens thickness showed decrease from the baseline readings with both eye drops. Effect of both the eye drops on over all axial length and vitreous chamber length is statistically seen, but is clinically negligible and not significant.

Hussain G. Ahmed,¹ Murtada AM Tom²

Abstract

Objectives: Degenerative changes caused by delays in urine preservation contribute to false-negative and false-positive interpretation of urothelial disease in cytology. The aim of this study is to assess whether the delay of fixation of urine samples makes any significant difference to urine cytology and morphology, and the limit of acceptability of delay for routine use in the hospital laboratory.

Methods: Three cell collection fluids were evaluated by analyzing the preservation and degeneration of cells in urine samples. In this study, 50 voided urine specimens were taken at random from females complaining of vaginal discharge. Each specimen was divided into three sterile containers. The first was immediately centrifugated and the deposit was smeared onto a cleaned micro slide and immediately fixed into 95% ethyl alcohol for 15 minutes. The remaining two were prepared in the same manner, however, the second after two hours of collection and the third after four hours of collection. The degree of degeneration and thus the preservation were assessed by a table of chosen criteria, then ranked and analyzed using Friedman's nonparametric test, atp=0.05.

Results: The results showed a significant difference between the preservation and the delay in urine fixation, p<0.0001.

Conclusion: Any delay in fixation of urine specimen for cytology affects the preservation of cells, which may result in miss diagnosis. It is recommended that urine samples for cytology should be fixed immediately after collection.

A Rare Early Complication of Tracheostomy

Manjeet Singh Pawar, Neelam Suri

Abstract

A polytrauma patient on ventilator was admitted to ICU with open tracheostomy, GCS 8/15 and unequal pupils. After 10 days, he was weaned from the ventilator. The patient had respiratory problems i.e. expiratory stridor, shortness of breath, dysphonia and dyspnea on closing tracheostomy. It was diagnosed as a case of asthma, and the patient responded to salbutamol nebulization and intravenous steroid therapy. However, after some time, he desaturated and a plan for rapid sequence intubation was made. Endotracheal tube could not be negotiated beyond vocal cords, so an unprepared tracheostomy without proper equipment had to be immediately done by an anesthetist to save the patient’s life. CT scan revealed tracheal stenosis. This case demonstrates that patients with a short 15-days history of previous tracheostomy may have tracheal stenosis.

Broncho-Oesophageal Fistula (BOF) Secondary to Missing Partial Denture in an Alcoholic in a Low Resource Country

 Vincent I. Odigie,1 Lazarus MD. Yusufu,1 Peter Abur,1 Sunday A. Edaigbini,2 David A. Dawotola,3 

Ahmad Mai,1 Samuel O. Ameh1

Abstract

The clinical course of a missing partial denture with secondary BOF in an alcoholic is presented. In the index case we report an exceptional clinical course of a patient who did not ascribe his symptoms to his ‘‘missing’’ dentures for several years, the odontologist who replaced an unrecovered denture, and the generalist who administered the barium swallow in an unsuspected BOF. Preoperative optimization of the patient was by blenderized local feeds through a feeding tube gastrostomy and by chest physiotherapy. Extraction of the denture and closure of fistula were done through a right thoracotomy. The importance of a high index of clinical suspicion of BOF in a low resource setting to avoid the morbidity and mortality associated with missing dentures is discussed. Odontologists, caregivers and clinicians must educate patients on the hazards of missing dentures and cases of missing / lost dentures should be adequately investigated / explored in the patient’s history and clinical assessment before they are replaced.

Tuberculous Mastitis Presenting as Breast Abscess

Leo Francis Tauro, John.S. Martis, Celine George, Aroon Kamath, Geover Lobo, B. Rathnakar Hegde

Abstract