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JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
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JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
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JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
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JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
Letter from the Editor
for publication and short after sending the papers some authors contact us requesting a letter of acceptance.
I want to clarify the procedure we are following to publish any article in our journal.
Soon after we receive the paper, we select 2 and sometimes 3 referees to review the article. We ask the referees to
send their comments not later than 4 weeks after receiving the article, unfortunately some of the referees take much
longer time before they send us their comments and some referees do not even respond.
Sometimes one referee sends his comments in favour of publication, the other referee sends against publication,
which makes us to send the article to a third referee and based on his comments we accept or do not accept the article
for publication. This means that in order to accept any paper two referees must give favourable comments. On the
other hand if two referees give unfevourable comments then this paper is not going to be published.
Many of the comments we are receiving are concerning with the weakness of language and the style, and therefore
I would like to ask those who want their papers to be accepted for publication to write their papers according to the
instructions to the authors, which we publish in each issue and to write the article in good English or Arabic language
without mistakes.
The next step is to send the comments to the author, so that he or she can correct some of the writing according to
what the referees suggest.
Our aim, as I said in previous issues, is to make this jouranl registered in the index medicus and unless we publish
good quality papers free of mistakes we can not do that.
Based on that and due to the fact that this journal is published every three months, it is impossible to give a letter
of acceptance in less than three months and to publish the article in less than three to six months.
We are trying our best to make the whole procedure faster by using the E-mail in our correspondence with the
authors and the referees, and therefore I am asking the authors to send their articles through the E-mail when they
send the hard copies, and to provide us with their E-mails so that we can communicate with them much faster.
From this issue onwards you will notice that we have changed the cover page to the better I hope. You will
also notice that the name of Arab Board of Medical Specializations has been changed to the Arab Board of Health
Specializations. The change of the name was decided in the last Arab Health Ministers Meeting held in Damascus in
March 2009.
The Arab Board will deal in the future not only with medical specializations, but also with postgraduate programs
in nursing and other health specialities.
I want to thank all our authors for their input and our readers for their comments and last but not least all our
referees for their efforts.
Professor M. Hisham Al-Sibai
Editor-in-chief
Secretary General of the Arab Board of Health Specializations
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JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
ABSTRACT
Objective: Diarrhea is one of the most common
childhood illnesses worldwide and exerts major nancial
impact. The presence of gross blood or an inammatory
response in the stool (leukocytes or lactoferrin)
signicantly increases the chance for isolation of
invasive enteric bacteria. Improved knowledge of the
microbiologic etiology of childhood diarrhea could help
clinicians make appropriate diagnostic and therapeutic
decisions and diminish the burden of these illnesses. The
aim of this work is to determine the predictive utility
of certain clinical and stool parameters in diagnosing
bacterial diarrhea.
Methods: A prospective one year study was conducted
on 142 patients, below 5 years of age, with acute
diarrhea, in Babylon Maternity and Children Teaching
Hospital (Outpatient and Emergency department)
Original Article
CLINICAL AND LABORATORY PREDICTORS OF ACUTE
BACTERIAL DIARRHEA
Jasim M. Al-Marzoki, CABP
142
2007
45.0764
9.3621.61468.744
92757592
8836.6
36.1917682
38 <
*Jasim M. Al-Marzoki, CABP, Department of Pediatrics, Babylon Medical College, Babylon University, Hilla-Iraq, Iraq.
E-mail: jasim_20042001@yahoo.com
3
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
during the months of January to December 2007.
Results: The positive stool culture was yield in
64 patients (45.07%). The isolated pathogens were
Escherichia coli in 44 patients ( 68.7%), Shigella spp. in
14 patients (21.6%), and Salmonella spp. in 6 patients
(9.3%). The best predictive variable for a stool culture
positive for a bacterial pathogen was the presence of
fecal leucocytes, with a sensitivity of 92%, a specicity
of 75%, and positive and negative predictive values of
75% and 92%, respectively, with odd ratio of 36.6. The
next predictive variable was the presence of both fecal
leucocytes and fecal blood with a sensitivity of 88%, a
specicity of 82%, and positive and negative predictive
values of 76% and 91%, respectively, with odd ratio
of 36.1. The best historical factors for predictive
accuracies were abrupt onset, fever≥38°C, abdominal
pain, frequent bowel motions and no vomiting before
the onset of diarrhea.
Conclusions: Examination of stool for fecal
leukocytes and fecal blood is a rapid, reliable, and
inexpensive way to be the best method of predicting a
positive stool culture, while detecting a blood in the
stool only had high specicity with low sensitivity.
INTRODUCTION
Diarrhea is one of the most common childhood
1
Every child encounters at least one diarrheal episode.2,3
In the developed countries, the incidence of intestinal
infections ranges from 1.2 to 1.9 episodes per person
annually in the general population, and is higher in
developing countries, and in some tropical areas may
<3 years of age.4,5
In vast majority of cases, acute diarrhea in children
is the sign of infection of the gastrointestinal tract.
In developed countries, most episodes, especially in
viral infections.6,7 The second prevalent group are
bacterial infections: Salmonella spp., Campylobacter
jejuni, Shigella spp. and E. coli.8,9 In developing world,
bacterial pathogens are more frequent in young children
of acute diarrhea.10
Rapid onset of liquid stools with or without accom-
panying symptoms or signs such as nausea, vomiting,
fever and abdominal pain comprise a clinical picture of
acute diarrheal disease. The presence of gross blood or
-
tion of invasive enteric bacteria.11,12
The majority of episodes of acute infectious diarrhea
in children are mild and resolve spontaneously without
diagnostic testing is usually required in acute, watery
diarrhea for the immunocompetent patient. Routine
stool cultures in acute diarrhea have a very low yield
13
Improved knowledge of the microbiologic etiology
of childhood diarrhea could help clinicians make
appropriate diagnostic and therapeutic decisions and
diminish the burden of these illnesses. Here we describe
the results of a prospective study designed to determine
factors associated with identifying a pathogen on
evaluation of stools of children with diarrhea in inpatient
and outpatient settings.
AIMS
To assess the value of presenting history, physical
examination, and screening laboratory tests in predicting
whether diarrhea in a young child is associated with a
positive stool culture for a bacterial pathogen.
METHODS
Study population: A prospective one year study
was conducted on 142 patients below 5 years of
age with acute diarrhea in Babylon Maternity and
2007.
Data collection: A standardized questionnaire,
designed to characterize the patient’s illness, addressed
vomiting, abdominal pain as well as diarrhea duration and
4
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
the number of bowel motions in 24 hours. Questionnaires
were in arabic language. The questionnaires were
self-administered or, when the patient’s literacy level
necessitated, by an interpreter. The temperature was
checked by the interpreter, and the patient was regarded
to be febrile if the temperature was °C.
Laboratory methods and data management:
Stool specimens were collected in escrow cap or by
rectal swabs and sent to the Babylon Maternity and
Children Teaching Hospital laboratory immediately and
inoculated on the susceptible available media.
Detection of bacteria: Established culture techniques
were used to isolate bacterial enteric pathogens.
On receipt, stools were plated on MacConkey agar,
Salmonella-Shigella agar, Tetrathionate broth, Hekto
agar, and a swab from the stool was inoculated in alkaline
peptone water, then after 4-6 hours transmitted to TCBS
Vibrio cholera
37oC in aerobic condition. These techniques are adequate
to identify and isolate Escherichia coli, Salmonella spp.,
and Shigella
genus of enterobacteria. Anti sera for shigella spp. and
Salmonella spp. were used also. There was no media for
detection and isolation for Campylobacter or Yersinia in
all the laboratories of Babil province, where the study
was done.
Additional laboratory investigation: Laboratory staff
recorded the presence of red blood cells by wet mount,
white blood cells by wet mount and Gram stain.
Statistics:
according to the results of stool culture to calculate
ratio. Chi-square test was applied to detect the level of
RESULTS
From the total 142 patients with acute diarrhea,
who were enrolled in this study, the male children
were 85, and the females were 57, with male:female
of 1.49:1. The positive stool culture was yield in
40
, and . One
hundred twenty seven patients had watery diarrhea,
and their stool cultures were positive in 54 patients
patients, and their stool specimens were positive in 10
patients . The isolated pathogens were E.coli
Shigella spp. in 14 patients
Salmonella spp.
with mean±SD=24.5± 12.2 months, and most of them
Figure 1.
The duration of diarrhea was ranging between
2.27 days, and most of the
patients had diarrhea of less than one week duration
2. The frequency of passing stool per day was ranging
between 1-16 days with mean±SD=6.20± 2.77/day,
best predictive variables for a stool culture positive for a
bacterial pathogen was the presence of fecal leucocytes,
respectively, with odd ratio of 36.6; and presence of
both fecal leucocytes and fecal blood with a sensitivity
odd ratio of 36.1. Temperature equal or greater than
38°C
Figure 1. Age distribution of patients.
5
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
Figure 2. Distribution of patients according
to the duration of diarrhea.
Figure 3. Distribution of patients according to the
frequency of passing stool per day diarrhea.
p-value
Odd
ratio
NPV
PPV
Sensitivity
No . of patients
with positive
stool culture
Total No. of
patients
Characteristics
<0.00136.69275759259
5
78
64
Fecal leucocytes
Yes
No
>0.057.057273826038
25
52
90
Fecal blood
Yes
No
<0.00136.19176828838
5
50
62
Fecal leucocytes and
blood
Yes
No
>0.050.75341514227
36
65
77
Vomiting
Yes
No
<0.0011.596248387146
18
94
48
Fever
>38°C
<38°C
<0.0012.36752477146
18
87
55
Abdominal pain
Yes
No
Table 1. History and examination at presentation and microbiology results
with their predictive variables.
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JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
respectively, with odd ratio of 2.3. The least predictive
variable for a positive stool culture was vomiting with
a sen
of 0.7, Table 1.
DISCUSSION
There are no published studies from Iraq on this
subject. This study was conducted to assess the
value of history, physical exami-nation, and screening
laboratory tests in predicting whether diarrhea in a
young child is associated with a stool culture positive
for a bacterial pathogen. There was no media for
detection and isolation for Campylobacter or Yersinia
in all the laboratories of Babil province, where the study
was done.
Escherichia coli
by Shigella spp. Salmonella spp.
while in other study, the commonest pathogens were
Escherichia coli followed by Salmonella typhi murium,
Vibrio cholerae and Shigella exneri.14
The best predictive variable for a stool culture positive
for a bacterial pathogen in this study was the presence
of fecal leucocytes, which is about to be similar to other
15,16 A study done on children below
17 The next predictive variable
was the presence of both fecal leucocytes and blood in
the stool. The presence of blood in the stool only had
to other study.18 The best historical factors for predictive
°C, abdominal
pain, frequent bowel motions and no vomiting before
the onset of diarrhea. Improved knowledge of the
microbiologic etiology of childhood diarrhea could help
clinicians make appropriate diagnostic and therapeutic
decisions and diminish the burden of these illnesses.
CONCLUSIONS
Examination of stool for fecal leukocytes and fecal
blood is a rapid, reliable, and inexpensive way to be
the best method of predicting a positive stool culture,
while detecting a blood in the stool only had high
°C, abdominal pain, frequent bowel motions and
no vomiting before the onset of diarrhea are the best
historical factors for predictive accuracies of a positive
stool culture.
ACKNOWLEDGMENT
The author greatly thanks Mr. Hamza Al-Awadi
this study.
REFERENCES
1. Avendano P, Matson DO, Long J, et al. Costs associated
with ofce visits for diarrhea in infants and toddlers.
Pediatr Infect Dis J 1993;12:897–902.
2. World Health Organization. World Health Report 1997:
conquering suffering, enriching humanity. Report of the
Director-General. Geneva: World Health Organization,
1997.
3. Bern C, Martines J, de Zoysa I, et al. The magnitude
of the global problem of diarrhoeal disease: a ten year
update. Bull WHO 1992;70:705–14.
4. Glass RI, Lew JF, Gangarosa RE, et al. Estimates of
morbidity and mortality rates for diarrhoeal diseases in
American children. J Pediatr 1991;118:S27–33.
5. Kotloff KL, Winickoff JP, Ivanoff B, et al. Global
burden of Shigella infections: implications for vaccine
development and implementation of control strategies.”.
Bull WHO 1999;77:651–66
6. Phavichtir N, Catto-Smith AG: Acute gastroenteritis in
children. What role for antibacterials?. Pediatric Drugs
2003;5:279–90.
7. Kapikian AZ. Viral gastroenteritis. JAMA 1993;269:
627–30.
8. Cohen MB. Etiology and mechanisms of acute infectious
diarrhea in infants in the United States. J Pediatr 1991;
118:S34–39.
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JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
9. Mrukowicz JZ, Krobicka B, Duplaga M, et al.
Epidemiology and impact of rotavirus diarrhoea in
Poland. Acta Paediatr 1999;426:53–60.
10. Chalmers RM, Salmon RL. Primary care surveillance for
acute bloody diarrhea, Wales. Emerg Infect Dis 2000;6:
412–14.
11. Talan DA, Moran GJ, Newdow M, et al. Etiology of bloody
diarrhea among patients presenting to US emergency
departments: prevalence of E.coli O157:H7 and other
enteropathogens. Clin Inf Dis 2001;32:573–80.
12. Huicho L, Campos M, Rivera J, et al. Fecal screening
tests in the approach to acute infectious diarrhea: a
scientic overview. Pediatr Infect Dis J 1996;15:486–
94.
13. Guerrant RL, van Gilder T, Steiner TS, et al. Practice
guidelines for the management of infectious diarrhea.
Clin Inf Dis 2001;32:331–50.
14. Jindal N, Arora S. Role of faecal leucocytes in the
diagnostic evaluation of acute diarrhea. Indian J Med
Sci 1991 Oct;45(10):261-4.
15. DeWitt TG, Humphrey KF, McCarthy P. Clinical
predictors of acute bacterial diarrhea in young children.
Pediatrics 1985;76(4):551-6.
16. Ascher DP, Edusada-Corpus R. Clinical and laboratory
predictors of bacterial diarrhea in a tropical environment.
Mil Med 1991 Feb;156(2):74-6.
17. Patwari AK, Deb M, Dudeja M, et al. Clinical and
laboratory predictors of invasive diarrhea in children
less than ve years old. J Diarrhoeal Dis Res 1993
Dec;11(4):211-6.
18. Bardhan PK, Beltinger J, Beltinger RW, et al. Screening
of patients with acute infectious diarrhoea: evaluation
of clinical features, faecal microscopy, and fecal occult
blood testing. Scand J Gastroenterol 2000 Jan;35(1):54-
60.
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JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
ABSTRACT
Objective: To study the prevalence, treatment and
prevention of nutritional rickets among children
presenting to Sam hospital in Sana’ a city.
Methods: Record-based descriptive study was done
in Sam hospital in Sana’a city during one year from
1 May 2007 to 31 April 2008. Out of 10800 patients
seen for different causes through that period, 114
(1.05%) had one or more symptoms and/or signs of
rickets such as wide fontanel, delayed teething, rosary
rickets, bow legs,...etc. Those patients subjected to
radiological investigations (wrist X-ray), and few of
them to laboratory investigations (alkaline phosphatase,
calcium and phosphorus). Data about age and sex were
also collected.
Results: Age group of the patients was 0-3 years.
Total patients were 10800, (6060 males, 4740 females).
PRESENTING TO SAM HOSPITAL IN SANA,A CITY, YEMEN
Mabrook Aidah Bin Mohanna, MD
:
D
D
Original Article
-
sity. P.O.Box 18660. E-mail. mabrookmohanna@yahoo.com.
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JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
Patients who had one or more symptoms and/or signs
of rickets were 114 (1.05%) (78 males, 36 females),
of those 80 (70.2%) conrmed diagnoses as rickets
by radiological, and laboratory investigations. Thirty
two patients out of 88 were in age group between 6-12
months, in addition to 32 patients in age group between
1-1.5 years.
Conclusions: The majority of the patients were
males, the prevalence of nutritional rickets was very
high, common in age 6-18 months. It is a common
problem among children in Sana’a city, hence immediate
treatment, by sufcient dose of vitamin D and calcium,
while prevention is throughout encouragement of
mothers, children and infants to exposed to sunlight and
to take diet rich in vitamin D and calcium.
Nutritional rickets remains prevalent among infants
and young children in many areas of Asia, North
America, and northern Europe, despite the availability of
among infants in many communities, particularly
among infants who are completely breast-fed, infants
and children of dark-skinned, infants and their mothers
in the Middle East, and infants and children in many
developing countries in the tropics and subtropics areas.
among young infants in most countries, since breast
milk is low in vitamin D and its metabolites, and social
and religious customs and/or climatic conditions often
prevent enough ultraviolet light exposure.1,2
Nutritional rickets is considered to be the most
common non-communicable disease of children. Over
one billion humans have inadequate circulating levels
common in developing countries. Rickets can be owing
either to primary lack of vitamin D or calcium or to
laboratory and radiologic resources, the diagnosis of
rickets is considered clinically when a child presents
with limb deformities and has beaded ribs and broadened
wrists and ankles. Apparently healthy children living
in areas where rickets is common have risk factors for
rickets and a small percentage will have evidence of
biochemical rickets.1,3
Nutritional rickets is a multifactorial condition.
Among these, lack of exposure to sunlight, long-
standing breast feeding without supplementation and
factors.4 Avoidance is probable throughout increased
sun exposure and dietary improvement. Treatment of
calcium. Further research is needed to clarify the precise
developing countries, to determine the roles of additional
pathologic factors contributing to the development and
morbidity of rickets, to improve reasonable and feasible
means of diagnosing rickets in resource-limited areas,
to recovered target at-risk populations for preventive
interventions, to identify accurate dosing and delivery of
therapeutic interventions, and to evaluate the long-term
childhood.3
Rickets in children has been well-known as a persistent
worldwide health concern largely through published case
series, retrospective chart reviews at local institutions
and cross-sectional studies.5-9 Reports have noted cases
not only from regions with more limited sunshine, such
as New Zealand,1011 and the United
States,9 but also from sunnier regions such as Africa,12
Saudi Arabia3 and Australia.13 Lack of sunlight exposure
recent immigration are the most common risk factors in
these reports.
Nutritional rickets seems to be a common problem
among infants in Jordan. Further studies at national
level are needed to determine the prevalence of rickets
in Jordan. Rachitic infants are commonly hospitalized
due to lower respiratory tract infections, thus there is a
high index of suspicion for rickets among hospitalized
infants with lower respiratory tract diseases.14
Nutritional rickets was epidemic among infants and
young children in many areas of Asia, North America,
and northern Europe. With the detection of the role
3
rickets,15 economical methods of
10
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
preventing and treating nutritional rickets became
available. Despite these developments, rickets remains
a major public health problem in many developing
countries16-20 and its prevalence is accounted to be
increasing in several developed countries.21-25
The aim of the study to determine the prevalence,
treatment and prevention of nutritional rickets among
children presenting to Sam hospital in Sana’a city,
Yemen.
METHODS
Record-based descriptive study was done in Sam
hospital Sana’a city during one year from 1/May/2007
to 31/April/2008. The hospital provides services to the
community through outpatient clinics and admissions
and receives patients from Sana’a city, surrounding areas
and sometimes from other governorates, beside referred
cases from private clinics. Out of 10800 patients seen
one or more symptoms and/or signs of the rickets, such
as wide fontanel, delayed teething, rosary rickets, bow
legs, and widened wrists and ankles, etc. Those patients
subjected to radiological investigations, and a few of
them to laboratory investigations according to the ability
of the family to pay for the investigations, to the doctor
who received the patients. Sometimes, many children
even without laboratory and radiologic resources, but
the diagnosis of rickets was considered clinically when
a child presented with limb deformities and had beaded
ribs and broadened wrists and ankles. Radiological
investigations such as left wrists X-ray which were
considered positive when there were a manifestations
investigations considered positive when alkaline
phosphatase was high, calcium was normal or low, and
phosphorus was low. Data about age and sex were also
collected.
RESULTS
Age group of the patients was 0-3 years. Total number
Patients that had one or more symptoms and/or signs
70
between 6-12 monthes years, and another 32 between
1-1.5 years, see Table 1.
Age group Males Females Total
<6 months 7 2 9
6-12 months 21 11 32
1-1.5 years 22 10 32
1.5-3 years 5 2 7
Total 55 25 80
Table 1. Frequency of nutritional rickets
according to ages.
In this study, presenting males with nutritional rickets
were more than females. This can be attributed to the
fact that many families in Yemen prefer males than
females, so they bring them early for medical advice.
Age group of the patients was 0-3 years. This is the
age of breast feeding, and the majority of the infants
in Yemen are on breast feeding. The breast milk is low
in calcium and vitamin D. Breast milk is indisputably
the ideal food for infants; however, breast milk typically
contains about 25 IU or less vitamin D per litre,26,27 which
evidence that limited sun exposure may prevent rickets
in some breast-fed infants,28,29 concern over the health
risks of sun exposure have led to the recommendation
that all breast-fed infants receive supplemental vitamin
who reside above the 55th latitude in Canada or in
areas at lower latitudes that have a high incidence of
months.30
In this study, the prevalence of nutritional rickets,
investigations, was very high, although not all children
who were clinically suspected to have rickets had
11
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
investigations. This may be due to multifactorial causes,
the mothers are completely covered by cultural use of
protective clothing, minimal exposed to sunlight, many
of them had closely spaced pregnancies, prolonged
lactation, and took poor diet in vitamin D and calcium. An
are rare now, but the latter occasionally develops in a
breast-fed infant whose mother was unaware of human
supplementary vitamin D.31-33 Dietary calcium intake
depends on the consumption of dairy products, almonds
and sardines and leafy green vegetables. The primary
method of prevention is to ensure maximum peak
bone mass by providing optimal calcium intake during
childhood and adolescence.31
In this study, the children who were clinically had
manifestation of rickets radio logical examination, and
a few of them laboratory investigations, that many
families were poor and unable to pay for investigations,
and sometimes the diagnosis of rickets was considered
clinically when a child presented with limb deformities
and had beaded ribs and broadened wrists and ankles.
The current study revealed that nutritional rickets was
more in age 6-18 months. This can be explained by the
fact that many parents search for medical advice only
when there are frank clinical manifestations of rickets
such as wide fontanel, delayed teething, rosary rickets,
bow legs, and widened wrists and ankles ...etc.
CONCLUSIONS
In conclusion, the prevalence of nutritional rickets is
very high and it was more in age 5 to 18 months. It is a
common problem among children in Sana’ a city, hence
calcium, while prevention is throughout encouragement
of mothers, children and infants to exposed to sunlight
and to take diet rich in vitamin D and calcium, in
addition to attention to maternal vitamin D status
during pregnancy and lactation, are warranted. Further
studies at national level to determine the prevalence of
nutritional rickets in Yemen are needed.
Pettifor JM. Nutritional rickets: deciency of vitamin D, 1.
calcium, or both. Am J Clin Nutr 2004 Dec;80(6):1725-
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Al-Mustafa ZH, Al-Madan M, Al-Majid HJ, et al. Vita-2.
min D deciency and rickets in the Eastern Province of
Saudi Arabia. Ann Trop Paediatr 2007 Dec;27(4):319.
Fischer PR, Thacher TD, Pettifor JM. Pediatric vitamin 3.
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Majid Molla A, Badawi MH, Al-Yaish S, et al. Risk fac-4.
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Binet A, Kooh SW. Persistence of vitamin D-deciency 5.
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Strand MA, Perry J, Jin M, et al. Diagnosis of rickets 6.
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Haworth JC, Dilling LA. Vitamin D-decient rickets in 7.
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Mylott BM, Kump T, Bolton ML, et al. Rickets in the 8.
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Weisberg P, Scanlon KS, Li R, et al. Nutritional rickets 9.
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Blok BH, Grant CC, McNeil AR, et al. Characteristics 10.
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Shaw NJ, Pal BR. Vitamin D deciency in UK Asian 11.
families: activating a new concern. Arch Dis Child
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Karrar ZA. Vitamin D deciency rickets in developing 12.
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Robinson PD, Hogler W, Craig ME, et al. The re-emerg-13.
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Najada AS, Habashneh MS, Khader M. The frequency of 14.
nutritional rickets among hospitalized infants and its re-
lation to respiratory diseases. Trop Pediatr Jdiatr 2004
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Rajakumar K. Vitamin D, cod-liver oil, sunlight, 15.
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Du X, Greeneld H, Fraser DR, et al. Vitamin D decien-16.
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Am J Clin Nutr 2001;74:494–500.
Harris NS, Crawford PB, Yangzom Y, et al. Nutritional 17.
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Oginni LM, Worsfold M, Oyelami OA, et al. Etiology of 19.
rickets in Nigerian children. J Pediatr 1996;128:692–4.
Muhe L, Luiseged S, Mason KE, et al. Case-control 20.
study of the role of nutritional rickets in the risk of
developing pneumonia in Ethiopian children. Lancet
1997;349:1801–4.
Finberg L. Human choice, vegetable deciencies, and 21.
vegetarian rickets. Am J Dis Child 1979;133:129.
Edidin DV, Levitsky LL, Schey W, et al. Resurgence of 22.
nutritional rickets associated with breast-feeding and
special dietary practices. Pediatrics 1980;65:232–5.
Iqbal SJ, Kaddam I, Wassif W, et al. Continuing clini-23.
cally severe vitamin D deciency in Asians in the UK
(Leicester). Postgrad Med J 1994;70:708–14.
Rowe PM. Why is rickets resurgent in the USA?. Lancet 24.
2001;357:1100.
DeLucia MC, Mitnick ME, Carpenter TO. Nutritional 25.
rickets with normal circulating 25-hydroxyvitamin D: a
call for reexamining the role of dietary calcium intake
in North American infants. J Clin Endocrinol Metab
2003;88:3539–45.
Nakao H. Nutritional signicance of human milk vi-26.
tamin D in the neonatal period. Kobe J Med Sci
1988;34:121-8.
Hollis BW, Roos BA, Draper HH, et al. Vitamin D 27.
and its metabolites in human and bovine milk. J Nutr
1981;111:1240-8.
Specker BL, Valanis B, Hertzberg V, et al. Sunshine 28.
exposure and serum 25-hydroxyvitamin D concen-
trations in exclusively breast-fed infants. J Pediatr
1985;107:372-6.
Greer FR, Marshall S. Bone mineral content, serum vita-29.
min D metabolite concentrations, and ultraviolet B light
exposure in infants fed human milk with and without vi-
tamin D2 supplements. J Pediatr 1989;114:204-12.
Canadian Paediatric Society. Vitamin D supplementa-30.
tion in northern Native communities. J Paediatr Child
Health 2002;7:459-65.
Teotia M, Teotia SPS, Nath M. Metabolic studies in con-31.
genital vitamin D deciency rickets. Indian J Pediatr
1995;62:55-61.
Behrman RE, Kliegman RM. Minerals (calcium). Nel-32.
son essentials of pediatrics. Third edition. Philadelphia
(PA): WB Saunders Company; 1998. p. 82.
Graef JW. Hypocalcaemia. Manual of Paediatric Thera-33.
peutics. 5th Egyptian ed. Cairo, Egypt: Mass Publishing
Co; 1996. p. 173.
13
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
ABSTRACT
Objective: To give an idea about thyroid diseases in
Iraq and the change in the behavior of the diseases and
the trends of the surgeons toward more radical surgery.
Methods: Two hundred and twenty four patients were
operated upon by the same surgeon during 15 years
period. Those patients were divided into two groups
(group I from June 1990 up to June 2000) and (group II
from June 2000-June 2005).
Results: Female to male ratio was 3.3:1. The
most common presentation among both groups was
Multinodular goiter (MNG) 76.8%. Toxic goiter was
recorded in 24% of patients with increase among group
II patients. A signicant effect of stress on the increasing
incidence of thyrotoxicosis was elicited in more than
50% of patients with thyrotoxicosis. Malignant thyroid
tumors constituted 8.5% of the diseases and they were
mostly papillary carcinoma. There was an increase in
the incidence of malignant thyroid tumors among group
II patients (2.65% in group I versus 13.5% in group
II). The trend toward more radical surgery was evident
among group II patients.
Conclusions: Thyroid malignancy and thyrotoxicosis
are increasing in our country and stress factor might
play a role in this rise. Due to the previous changes,
the surgeon attitude had changed toward more radical
surgery.
CHANGING PATTERNS OF THYROID PATHOLOGY
AND TRENDS OF SURGICAL TREATMENT
Tharwat I. Sulaiman, FRCSI, CABS
224
2005200020001990
24GNM
stress
2.65
13.5
Original Article
*Tharwat I. Sulaiman, FRCSI, CABS, Department of Surgery, Baghdad University, Baghdad, Iraq. E-mail: tharwatsulaiman@yahoo.com.
14
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
INTRODUCTION
Thyroid diseases are common allover the world,
but the incidence of different pathologies was variable
replacement. It was evident that there were changes
in the pathology in developing countries where there
thyroid cancer.1 Papillary carcinoma is the most prevalent
endocrine malignancy, and the reported incidence of
papillary carcinoma has more than doubled in many
countries during the past half century.2,3
In recent years, there have been also many reports
about the possible association between stressful life
4,5
Surgery for differentiated thyroid malignancy should
be more radical, but controversy remains regarding the
best surgical approach for toxic Multinodular goiter6
7
In this study, we tried to outline some features of
thyroid diseases in Iraq, and elucidate whether there
was a change in the behavior of the diseases and
clinical types. The effect of stress on the incidence of
thyrotoxicosis was studied and compared to the effect
change in surgical management trends during this period
of 15 years.
METHODS
This is a prospective review involving 224 patients
with thyroid diseases operated upon by a single surgeon
during 15 years period from June 1990 till June 2005.
The patients were seen in a private clinic and operated
upon either in Baghdad teaching hospital or Hammad
Shihab teaching hospital or in private hospitals. About
thirty patients were dropped from the study due to
incomplete data. The patients were divided into two
during the period from June 1990 till June 2000, and
June 2000 till June 2005.
information including age, residency, personal history,
family history of thyroid disease, history of thyroid
problem, results of physical examination, investigations,
and the type of surgery performed with the results of
histopathology. Special attention was given to the age,
sex, history of stress in thyrotoxic patients, type of
were investigated as those events which put the patient
under high stress like the death of one of the relatives, job
loss, or severe psychological trauma. Hormonal assay
including T3, T4, TSH was done, while thyroid scan
was done for few patients due to unavailability. Ultra
most patients in GII and few patients in GI because it
was not available at the early years of the study.
RESULTS
The total number of patients was 224 patients with
Group I Group II Total
No. No. No.
Male 32 20 52
Female 73 99 172
Total 105 119 224
Male: female=1:3.3, p=<0.005
Table 1. Distribution of thyroid diseases
according to sex.
The majority of patients in both groups were resi-
dents in Baghdad and central governorates of Iraq, as
were from these parts of the country.
Clinically the most common presentation was
compared to GI while the opposite was true for MNG.
15
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
Group I Group II Total
No. No. No.
Solitary
nodule 22 21 12 10.1 34 15.2
Diffuse goiter 8 7.6 10 8.4 18 8
Multinodular
goiter 75 71.4 97 81.5 172 76.8
Total 105 119 224
Table 2. Clinical presentations of goiter by study
groups.
being more
between the two groups regarding the occurrence of
Group I Group II Total
No. No. No.
Toxic 22 21 32 27 54 24
Non toxic 83 79 87 73 170 76
Total 105 119 224
Table 3. Thyrotoxicosis among GI and GII.
The occurrence of thyrotoxicosis in GI was
ratio was about 1:3, most of the patients with toxic
to the establishment of thyrotoxicosis in 7 out of 22
to the much higher prevalence in GII as it was present
GII.
Thyroid malignancy was diagnosed in 19 patients
tumors of thyroid were much more common among GII
Table
in GI were papillary carcinomas and all of them were
diagnosed postoperatively because there was no facility
to do FNA at that time. One patient in GI presented with
solitary nodule with no lymph nodes metastasis while
the other two patients presented as MNG and one of
them had lymph nodes metastasis.
Other types of malignant tumors were diagnosed in
GII. Follicular carcinoma was recorded in one patient
and non Hodgkin’s lymphoma in other patient and two
patients had follicular variant of papillary carcinoma.
Metastasis of papillary carcinoma to the cervical lymph
nodes in GII was recorded in seven patients; four of
them presented primarily with palpable cervical lymph
nodes which were proved to be metastatic papillary
carcinoma. In one patient with follicular carcinoma the
Male Female Multinodular Goiter Solitary Nodule Diffuse Goiter Total
No. No. No. No. No. No.
GI 10 45.5 12 54.5 18 82.6 1 4.5 3 13.6 22 21
GII 4 12.5 28 87.5 21 65.6 2 6.2 9 28.2 32 27
Table 4. Distribution of thyrotoxicosis by sex, type of goiter and groups.
16
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
metastasis was to the pelvic soft tissue as he presented
with large gluteal soft tissue mass and FNA yielded
adenocarcinoma. Thorough investigations proved the
mass to be metastatic follicular carcinoma of thyroid
origin.
Type of
tumor
GI=105 GII=119 Total=224
No. No. No.
Papillary
carcinoma 3 2.65 14 11.8 17 7.14
Follicular
cacinoma - 1 1.68 1 0.44
Lymphoma - 1 1.68 1 0.44
Total 3 2.65 16 13.44 19 8.5
Table 5. Types of malignant thyroid tumors by groups.
Cases of malignant tumors in both groups were
equally distributed between central part of Iraq and
southern parts as there were 9 patients from the central
part of Iraq and another nine patients from the southern
part of Iraq. Only one patient with malignancy was
from the northern part. All the patients involved in
this study underwent surgical treatment and the types
of surgery were either subtotal thyroidectomy, near
total thyroidectomy, or total thyroidectomy. The most
common operation was subtotal thyroidectomy in both
Near total thyroidectomy was more common in GII
Procedure
GI GII Total cases
No. No. No.
Subtotal
thyroidectomy 98 93.3 83 69.75 181 80.8
Near total
thyroidectomy 7 6.6 32 26.9 39 17.4
Total
thyroidectomy - - 4 3.4 4 1.8
Table 6. Types of surgical operations in GI and GII.
The incidence of complications varied between the
two groups Simple wound haematoma was
the commonest complication and it was more common
among GII patients. Other mild complications like
stitch abscess or granuloma were less common. Serious
complications in the form of recurrent laryngeal nerve
in GII. Two of those in GII had bilateral recurrent
laryngeal nerve palsy following surgery for third time
recurrent goiter in one patient and following near total
thyroidectomy for non Hodgkin’s lymphoma in the
other patient. Both patients were managed by temporary
tracheoastomy for few weeks with eventual cure.
Temporary hypocalcemia was detected in 6 patients;
supplementation of calcium for few days. Only two
weeks with resultant cure. Three of those with temporary
hypocalcemia developed symptoms of hypocalcemia
following surgery for toxic goiter.
Recurrent goiter was seen mostly in GI, while it
could not be assessed in GII because many patients
failed to show for follow up. Recurrent thyrotoxicosis
was equally distributed among the two groups.
Complications GI GII Total
No. No. No.
Wound
haematoma 1 0.95 9 7.5 10 4.5
Unilateral
recurrent
laryngeal
nerve palsy
1 0.95 2 1.7 3 1.3
Bilateral
recurrent
laryngeal
nerve palsy
- - 2 1.7 2 0.9
Superior
laryngeal
nerve injury
- - 4 3.4 4 1.8
Hypocalcemia 1 0.95 5 4.2 6 2.7
Stitch
granuloma 4 3.8 1 0.85 5 2.2
Recurrent
goiter 3 2.85 unknown - - -
Recurrent
thyrotoxicosis 2 1.9 2 1.7 4 1.8
2 1.9 2 1.7 4 1.8
Table 7. Distribution of postoperative complications by
groups.
17
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
DISCUSSION
In the present study thyroid diseases were more
consistent with many previous studies.8-14 This female
preponderance did not change during the study period.
The possible explanation for this result is the increase
need for iodine by females especially during puberty,
pregnancy and lactation, and possibly the dietary iodine
which is Iraq.
The most common clinical presentation was
or toxic MNG in both groups, although in recent years
there was a slight increase in the occurrence of diffuse
but there was also increase in the occurrence of MNG.
This high occurrence of MNG in Iraq is nearly similar
the neighboring countries like Turkey.15
as a representative of Asia, a national study adopted
the most common followed by follicular adenoma and
lastly carcinoma.18,19
9
In Africa, different studies revealed different results.
In a study carried in Uganda, diffuse colloid goiter was
twice as common as nodular goiter,12 while in Guinea
the studies showed solitary nodule to be the most
common clinical diagnosis.11 In Ethiopia, MNG made
18 These
differences can be explained by different levels of iodine
in the diet which might play a role in the pathogenesis
of nodular goiter.
Thyrotoxicosis was common among patients in
increase incidence of thyrotoxicosis over the years
of the study especially among female patients. A
similar increase in thyrotoxicosis was also detected
in other countries especially in Africa like Nigeria,13
Ethiopia,18 and Uganda.20 The increasing occurrence of
thyrotoxicosis in these countries was attributed to the
increasing use of iodized salt to combat endemic goiter,
a cause which might play a role in Iraq where iodized
salt was introduced during the last two decades.
especially among patients who already had goiter.
This study was carried over a very stressful period in
the history of Iraq, characterized by war and economic
sanction. These events put a severe burden on Iraqi
people, so we propose, as suggested by previous workers
the stress of similar events as in Serbia, Nigeria, or
Portugal that stressful life conditions might be the cause
of increase incidence of thyrotoxicosis.4,5,12-14
The current study demonstrated that increase
occurrence of thyrotoxicosis was mainly among
4,5 in
two studies proving a relationship between Systemic
attributed the association between Grave’s disease and
stress to the effect of SLEs on immune system of the
patients. They also demonstrated that SLEs do not seem
to have any conclusive relationship with the onset of
toxic MNG.
In Serbia which had passed through similar war
conditions and stress, Panskovic N, et al also reported
increase incidence of Grave’s disease and he also put
SLEs as one of the provoking factors.
couldn’t detect in other studies, the fact that most of the
patients with thyrotoxicosis were below the age of 40.
effect of stress on the development of thyrotoxicosis, as
people in this age group are usually suffer more than
other age groups from the stress of life events.
The increasing occurrence of thyrotoxicosis in
female patients in the present study might also support
this assumption. Due to the situation of war and military
action, women became increasingly responsible for
daily life activities which put them under higher stress
18
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
as compared to the normal situation where they had a
more relaxed life style.
was the changing incidence of malignant tumors of
most prevalent endocrine malignancy, and the recorded
incidence of PTC has been more than doubled in many
countries, especially in the West, during the past half
century.2,3,8
In Ireland, studies showed a breakdown of thyroid
carcinoma over a 10 year period in which also
papillary carcinoma was the most common thyroid
malignancy.22 In Ukraine, the results of studies
following Chernobyl accident showed an increase in
papillary microcarcinoma.19
rise in the cases of thyroid malignant tumors over the
period of the study and papillary carcinoma was the
most frequently detected type.
In other Asian countries as in Sirelanka,1 a similar
preponderance of papillary carcinoma was reported with
decreasing incidence of anaplastic carcinoma which
was attributed to the use of iodized salt, but a similar
conclusion can not be made from the present study as
anaplastic carcinoma was not reported .
reported to be high and the most common type was
of thyroid carcinomas.10,23
In Africa, the picture is different as in Nigeria where
the overall occurrence of malignant thyroid tumors is
similar to the results of this study, but the most common
type was the well differentiated follicular carcinoma.21
In Ethiopia, the incidence of malignant thyroid tumors
common type in one study,24 while in another study the
incidence of differentiated thyroid carcinoma was much
11
In countries neighboring to Iraq, as in Turkey, an
increased prevalence of carcinoma was reported after
Chernobyl disaster.9 In Saudi Arabia, which is another
neighboring country to Iraq, they reported a similar
incidence of thyroid carcinoma to ours and again
papillary type was the commonest, but they reported
a higher incidence of other types of carcinoma. Their
results also showed malignant tumors to be more
common in male patients rather than females.11,25
For patients included in the present study there was
no difference in the distribution of malignant thyroid
tumors related to Iraqi governorates. The lower
frequency in patients from the northern parts of Iraq
is not factual because during that period of the study
the political situation did not permit free movement of
patients from the northern parts to Baghdad.
During the last decade there was a change in the
behavior of surgery towards more radical surgery as
toxic MNG.2 It was found that TT and NTT are safe and
effective approach in these conditions and in thyroid
carcinoma.7
Due to the changes of the pathologies of thyroid
gland, and the change in the behavior of surgeons
allover the world toward more radical surgery, there was
a real change in the extent of surgical excision of the
gland. During the early period of this study the surgery
most commonly conducted was subtotal thyroidectomy
the use of more radical procedures especially near total
thyroidectomy and to lesser extent total thyroidectomy.
This change in the attitude towards more extensive
surgery was mostly due to the increase in the incidence
of thyroid carcinoma among the second group. It was
also observed that although recurrent MNG was not very
for GII patients was associated with no recurrence at
least during the study period.
In fact, the increasing use of TT and NTT in our
practice was following the changing practice in
the west,15,26 but in the developing countries, the most
common surgical procedure employed is still STT.10
This change in the behavior does not seem to be
associated with rise in the complications,15,26 as it is also
19
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
evident in the present study through the comparison of
complications in both groups.
CONCLUSIONS
thyrotoxicosis could be due to increasing stressful life
conditions affecting Iraqi population, but this should be
studied more thoroughly well in future studies involving
more patients to be more representative.
The rise in the number of malignant thyroid tumors
especially papillary carcinoma may also be due to stress,
or changing type of diet, or to exposure of Iraqi people
to depleted uranium or other pollutes. This again needs
further studies to prove.
The changing behavior toward more extensive
surgery is safe and better for managing carcinoma, toxic
goiter and large MNG.
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Ranmtatunga PC, Amarasinghe SC, Ratnatunga NV. 1.
Changing pattern of thyroid cancer in Sri Lanka:
Has iodine programme helped?. Ceylon Med J 2003;
48(4):125-8.
Burgess JR, Tucker P. Incidence trends for papillary 2.
thyroid carcinoma and their correlation with thyroid
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2006 Jan;16(1):47-53.
Burgess JR. Temporal trends for thyroid carcinoma in 3.
Australia: An increasing incidence of papillary thyroid
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Santos AM, Nobre EL, Garcia e Costa J, et al. Graves 4.
disease and stress. Acta Ned Port 2002;15(6):423-7.
Matos Santos A, Nobre EL, Garcia e Costa J, et al. 5.
Relationship between the number and impact of stressful
life events and the onset of Graves disease and toxic
nodular goiter. Clin Endocrinol (Oxf) 2001;55(1):15-9.
Alimoglu O, Akdag M, Sahin M, et al. Comparison 6.
of surgical techniques for treatment of benign toxic
multinodular goiter. World J Surg 2005;29(7):921-4.
Delbridge L, Guinea Al, Reeve TS. Total thyroidectomy 7.
for benign multinodular goiter: Effect of changing
practice. Arch Surg 1999;134(12):1389-93.
Deasi G, Islam R. The changing pattern of surgical 8.
pathology of the thyroid gland in zambia. Cent Afri J
Med 1992;38(6):240-2.
Taneri F, Kurukahvecioglu O, Ege B, et al. Prospective 9.
analysis of 518 cases with thyroidectomy in Turkey.
Endocr Regul 2005 Sep;39(3):85-90.
Sinha SN, Sengupta SK. Surgical thyroid disease in Papua 10.
New Guinea. Aust NZ J Surg 1993 Nov;63(11):878-82.
Qari FA. Pattern of thyroid malignancy at university 11.
hospital in Waestern Saudi Arabia. Saudi Med J 2004
Jul;25(7):866-70.
Zubovic I, Mikac G, Biukovic M, et al. The frequency 12.
of thyrotoxicosis in war time period. Med Pregl 1993;
Suppl 1:85-6.
Ameh EA, Nmadu PT. Thyrotoxicosis in Zaria, Nigeria: 13.
An update. East Afr Med J 1997 Jul;74(7):433-4.
Paukovic N, Paukovic J, Pavlovic O, et al. The signicant 14.
increase in incidence of graves disease in estern serbia
during the civil war in the former Yugoslavia (1992-
1995). Thyroid 1998 Jan;8(1):37-41.
Hong EK, Lee JD. A national study on biopsy conrmed 15.
thyroid diseases among Koreans: An analysis of 7758
cases. J Korean Med Sci 1990 Mar;5(1):1-12.
Serra M, Mandez MA, Baxarias J, et al. Thyroid 16.
pathology in health center. Aten Primaria 1995 Apr
30;15(7):457-60.
Messele G, Tadesse B. Changes in the pattern of thyroid 17.
surgical diseases in Zewditu Hospital, Addis Ababa.
Ethiop Med J 2003 Apr;41(2):179-84.
Avestisian IL, Gulchiy NV, demdiuk AP, et al. Thyroid 18.
pathology in residents of The Kiev Region, Ukrane,
during pre- and post- Chernobyl periods. J Environ
Pathol Toxicol Oncol 1996;15(2-4):233-7.
Cardozo LJ, Viegas OA. Thyroid diseases in Uganda. 19.
Trop Geogr Med 1974 Sep;26(3):261-4.
Edino ST, Mohammed AZ, Ochicha O. Thyroid gland 20.
diseases in Kano. Niger Postgrad Med J 2004 Jun;
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O’Hanlon DM, Litle MP, Given HF, et al. Thyroid 21.
diseases in the west of Ireland: An atypical incidence of
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Park SH, Suh EH, Chi JG. A histopathological study on 22.
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1988 Dec;18(4):297-302.
Tsegaye B, Ergete W. Histopathological pattern of thyroid 23.
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Al-Rkabi AC, Al Omran M, Cheema M, et al. Pattern 24.
of thyroid lesions and the role of ne needle aspiration
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3):137-44.
20
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
ABSTRACT
Objective: To evaluate the prevalence of hepatitis
B and C infection among hemodialysis unit patients
and staff. Furthermore, to study the characteristic of
patients and risk factors of exposure.
Methods: Cross-sectional descriptive study of 123
patients in hemodialysis unit of Al-Thawra General
Modern Hospital and 20 staff of this unite in the period
starting from February 2005 till the end of October
2005.
Results: The ratio of men to women in this study was
2:1, while men to women ratio who got infection was
2.2:1. The mean age was 39 years with high incidence
SCREENING OF HEPATITIS “B” AND “C” IN HEMODIALYSIS UNIT IN
AL-THAWRA GENERAL MODERN HOSPITAL, SANA’A 2005
BC
2005
Yahya A. Al-Ezzi, MB.B.Ch;MB.B.Ch; Faiza S. Askar, MB.B.Ch
Original Article
CB:
20
123
20052005
1:2.2
39 50-3039
BC
ALT-SGPT38
B15
C
10BC
B
*Yahya A. Al-Ezzi, MB.B.Ch, Faculty of Medicine and Health Sciences, Sana a University, Sana a, Yemen. E-mail: Dr_khaled_alaghbari@yahoo
*Faiza S. Askar, MB.B.Ch, Faculty of Medicine and Health Sciences, Sana a University, Sana a, Yemen.
21
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
in the age group of 30-50 years. Thirty nine percent of the
patients were positive for hepatitis C virus antibodies,
while 8% were positive for hepatitis B surface antigen,
and 17% were positive for both. Thirty eight percent of
the patients were in active stage have raised (SGPT)
enzyme as a marker. The percentage among staff
members in this department was 15%. All of them were
positive for hepatitis B surface antigen (two doctors
and a nurse), non were positive for hepatitis C virus
antibodies. This study sh21owed that hemodialysis is a
risk factor for contracting viral hepatitis with increase
in the frequency of exposure and duration of the dialysis.
There were other risk factors like blood transfusion,
injections, level of education, exposure to surgery, but
with lesser risk than hemodialysis per se.
Conclusions: Increase percentage of infection with
hepatitis C by 10 folds and double that one with hepatitis
B of the general population. Reevaluation of regulations
and rules must be reconsidered. Staff must be well-
trained and educated about measures to avoid infection
and to be vaccinated against hepatitis B infection.
INTRODUCTION
Hepatitis is by far one of the major health problems
in Yemen and considered to be the ninth of common ten
endemic diseases that play a role in morbid-
ity in Yemen.1
Hepatitis is a big and serious problem because it
is responsible for long term complications where an
estimated 1 million people die annually from hepatitis
B virus related to chronic liver disease or primary
hepatocellular carcinoma, furthermore there is no
measure that may stop the progression and
prevent the complication of this disease.2 Hepatitis C
virus infection is emerging as a major public health
problem worldwide. It is a blood born pathogen that is a
major etiology of post transfusion hepatitis. The major
mode of hepatitis C virus morbidity associated with
its infection is related to chronic infection. In contrast
hepatitis B virus where only about develop
chronic infection, most hepatitis C virus infected person
develop chronic infection. Estimations derived
from regional data on prevalence of infection in the
general population indicate that 360 million people
worldwide have chronic hepatitis B virus infection,
in Asia, in Africa, in Europe, North America
and Oceania combined.2 In 1998, a seroepidemiologic
survey of 879 volunteers in different areas of Yemen
indicated that of the adult population had evidence
of chronic hepatitis B virus infection.3 In study of Yemeni
adults living in Saudi Arabia, had chronic hepatitis
B virus infection.3 Data from screening of blood donor
in Sabeen hospital indicate that were hepatitis B
surface antigenHBsAg compared to
of patients in Al-Thawra General Modern Hospital
GMH and of blood donors screened at the
Central Laboratory.3 The prevalence of hepatitis C virus
infection in Yemen was 4 Since the introduction
of hemodialysis in 1960s5, the prognosis and quality of
life of patients in end stage renal failure have greatly
improved, but in the last few years a general believe has
been developed stating that there is strong association
between hemodialysis and hepatitis B and C infection.
Hepatitis C viral infection seems to be important
cause of chronic liver disease in dialyzed patients6
The depressed immunity, frequent instrumentation and
needs for blood transfusion are the main factors that
predispose to viral hepatitis in patients with end stage
renal failure. Prevalence of hepatitis C viral infection is
very high among patients with end stage renal failure.
There are 6 centers for hemodialysis in Yemen; two
centers in Sana’a, one in Al-Thawra GMH that was the
and only referral one in Yemen for long time; the
second one is the Military Hospital; and the rest are in
Taiz Center, Al-Hudaida, Hajja, Aden and Al-Mukalla.
METHODS
This is a cross sectional study carried out in
hemodialysis unit in Al-Thawra GMH in Sana’a starting
from February till the end of October 2005. This study
included 123 patients who are known to have chronic
renal failure and programmed on hemodialysis. We
excluded everyone who is known to be hepatitis B or C
positive before dialysis in order to keep the subject of
studying the duration of hemodialysis as a risk factor of
infection valid. We also included 20 health workers8
doctors and 12 nurseswho are working in the dialysis
22
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
unit in the hospital and are negative for hepatitis B
and C markers before starting to work in this unit or
before joining the hospital. Data were collected from
the candidate by direct interview during his presence for
dialysis. The interview included questionnaire, which
include personal history, age, sex, occupation, residence,
duration of the disease, frequent of dialysis, history of
previous blood transfusion, surgery and education level.
Then everyone was subjected to full clinical exam.
Blood samples were examined to investigate Alanine
HbsAgand hepatitis C virus
antibodiesHCVAband in certain patients; hepatitis
B core antibodiesHbcAbto cover the window time.
It is a routine in this hospital to screen all patients for
hepatitis B surface antigen, hepatitis C virus antibodies
and HIV. The hospital lab used Axsym system Abbot
® with sensitivity of and of
to detect hepatitis markers.
RESULTS
A total of 123 patients were involved in this study, 85
men and 38 women. The mean age was 39 years with
high percentage in the age group of 30-50 years.
Table 1 demonstrates that most of the patients
were from Sana’a, were illiterate; while were
highly educated, of the patients were non smokers
and non Qat chewers, were farmers, were
employee and were house wives. Table 2 shows
that of the patients present in the age group 30-39
years, in the age group 40-49 years and in
the age group above or equal 50 years. Anti hepatitis
C virus was detected in 48 patientsHBsAg was
detected in patients while 21 patients
were positive for HCVAb and HBsAg, Table 3.
Table 1. Characteristics of patients undergoing
hemodialysis.
Table 2. Number of patients according to age
and sex.
Feature No.
Sex Male 85
Female 38
Residence
Sana’a 49
Al-Hudaida 20
Ibb 15
Others 39
Occupation
Farmer 27
Employer 23
House wife 31
Unemployed 10
Others 32
Level of
education
Illiterate 63
Read and write 27
Basic 20
Secondary 9
University 4
Habit
Smoker 3
Qat 16
Both 25
Non 79
Age in years Male Female Total
< 20 7 1 8
20-29 20 4 24
30-39 22 18 40
40-49 19 9 28
17 6 23
Total 85 38 123
HBV HCV HBV+HCV Negative Total
Number 10 48 21 44 123
Percentage
Table 3. The results of serological tests among patient on hemodialysis.
23
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
Tables6 a,bshow that the highest incidence of HCV
infection is in the age group 40-49 years11 for
men and5 for women. The men to women ratio
of viral hepatitis in this department was 2.2:1; of
the women got HCV infection, got HBV infection
and got both hepatitis B and C infection and the
rest were negative for either, comparing to for
HCV, for HBV and for both among men.
Among newly detected HCV cases, have raised
ALT levels as shown in Table 7.
Table 8 demonstrates that 4 of the staff in the hospital
worked for less than 1 year, while 8 of them worked for
Tables4 a,bdemonstrate that of the patients
had got HCV, HBV and 9.1 for bothHCV and
HBVin a period of 6 months to 1 year of dialysis, com-
pared to of HCV, none of HBV and of both
in a period more than 5 year.
Table 5 reveals that of the patients who
underwent surgical interference were positive for
HCVAb, for hepatitis B and C, but none for
HBsAg, whereas and were negative for both. In
spite that about of the patients had no past history
of surgical interference and developed HBsAg,
developed HCVAb developed both, and
were negative for both.
Type of infection
With
previous surgery
Without
previous surgery
No. No.
HBV 0 0 10
HCV 20 28
HBV + HCV 8 13
Negative 11 33
Total 39 84
Duration of
dialysis
HBV HCV HBV+HCV Negative Total
No. No. No. No.
1 -<6 months 5 6 1 27 39
6-12 months 2 3 1 5 11
>1 year 3 39 19 12 37
Total 10 48 21 44 123
Table 4a. The relationship between duration of dialysis and risk of infection.
Duration of
dialysis
HBV HCV HBV+HCV Negative Total
No. No. No. No.
1 - < 3 years 1 13 7 3 24
3 - 5 years 2 9 8 3 22
> 5 years 0 0 17 4 6 27
Total 3 39 19 12 73
Table 4b. Duration greater than one year and risk of infection.
Table 5. Percentages of HBV, HCV or both among patients underwent
previous surgical operations for other reasons.
24
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
Age group
in years
Male
Total
Female
Total
Positive Negative Positive Negative
HBV HCV Both
HBV HCV Both
<20 No. 2 3 0 2 7 0 0 1 0 1
28.6 42.9 0 28.5 100 0 0 100 0 100
20-29 No 0 6 5 8 19 0 1 1 2 4
0 31.6 26.3 42.1 100 0 25 25 50 100
30-39 No 2 6 4 11 23 3 5 5 5 18
8.7 26.1 17.4 47.8 100 16.6 27.8 27.8 27.8 100
40-49 No 1 11 4 3 19 2 5 0 2 9
5.3 57.9 21 15.8 100 22.2 55.6 0 22.2 100
>50 No 0 8 1 8 17 0 3 0 3 6
0 47 6 47 100 0 50 0 50 100
Normal SGPT High SGPT
49 30
Table 7. The result of serum glutamic pyruvic
transaminase SGPT among infected patients.
HBV HCV HBV+HCV Negative HBV HCV HBV+HCV Negative
No. 5 34 14 32 5 14 7 12
Table 6a. The results of serological tests according to sex.
Occupation Duration of work Immunization
against HBV Result of serological tests
Doctor Nurse < 1
year
1-5
years
> 5
years Yes No HBsAg HCV Ab
Positive Negative Positive Negative
8 12 4 8 8 7 13
3
17 0 20
2 doctor 1 nurse
Table 6b. Results of serological tests according to age and sex in numbers
and percentages.
Table 8. Risk of hepatitis in medical and paramedical staff in dialysis unit.
25
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
more than 5 years. They are 8 doctors and 12 nurses; 7
of them were actively immunized against HBV infection
before starting working in this department. Serological
studies show that two doctors and a nurse were HBsAg
positive. There is no information to tell who of the
three positives as regards immunization, job and years
of work. No one of the medical staff was infected with
HCV.
DISCUSSION
The present work shows that HCV infection
percentage in hemodialized patients is 10 folds of that
4
The percentage of HCV infection among the staff of the
hemodialysis unit is nil. The prevalence of hepatitis C
virus infection is very high among patients with end stage
renal failure particularly those under hemodialysis.7-10
The prevalence of HCV infection worldwide ranges from
1011 12
the USA,13 14 15
Serbia,1617 So from all of the
above we can see that the percentage of HCV infection
is 4 folds than that of the USA, while it is similar to that
of Arab countries and it is double of that of European
countries. The above result is explained by the fact that
most patients are poorly health educated, the health
workers are also poorly trained with ignorance toward
methods of infection, and the system of screening of
HCV infection only started in 1996 in the renal units
in Yemen, and the same is applied to the most Arabic
explanation why HCV infection among the staff is nil.
1 On the other
hand, the percentage of infection by both hepatitis B
18-21 The percentage of hepatitis
viral infection among the staff in the dialysis unit in Al-
population, and this can be explained that most health
workers are poorly educated and are ignorant of the
methods of infection by viral hepatitis and no previous
studies or screening were conducted before the 2005,
in addition to the frequent contact of staff with patients
and hemodialysis machines more than the patients
themselves. Other studies conducted in other countries
showed very low incidence of contracting viral hepatitis
among health workers which even dropped with time
16,22 There was no relationship between sex and
percentage of viral hepatitis and this was similar to a
study conducted in Italy.23 On the other hand, a study
was carried out in the United Arab Emirates showed
that the incidence of viral hepatitis is more in men
than women in hemodialysis unit.24 There was a strong
relation between increase of age and infection, where
the most affected age group in male was 40-49 year and
in female 30-35 years. This relation has been proved
in other studies worldwide.25,26 There was no relation
between frequency of dialysis -which is 2 times per
week- and increase risk of infection in contrast to other
studies.27,28
CONCLUSIONS
Increase percentage of infection with hepatitis C by
10 folds and double that one with hepatitis B of the
general population. Reevaluation of regulations and
rules must be reconsidered. Staff must be well-trained
and educated about measures to avoid infection and to
be vaccinated against hepatitis B infection.
REFERENCES
Al-Haddad A. Common endemic disease in Yemen. Yem 1.
Med J 1996;2(1):23-35.
Kundsen F, Wantz in P. Hepatitis C virus in dialysis 2.
patients. Denmark Kidney Int 1993;43(6):1353-6.
Mahoney F. Viral hepatitis in republic of Yemen. Yem 3.
Med J Dec 1998;2(1):12-21.
Al-Haddad A, Al-Khamisi R. Acute liver disease caused 4.
by hepatitis B. Yem Med J Oct 1995;1(2):59-66.
Hayash J. Prevalence of antibodies to hepatitis C virus 5.
in hemodialytic patients. Amer J of Epd 1991;13(6).
Altr M, Hadler SC. Risk factors for acute non-A non-B 6.
hepatitis in the United State and association with hepatitis
C viral infection. JAMA 1990;264:2213-35.
Nui MT, Cloeman PJ, Alter MJ. Multi center study 7.
of hepatitis C virus infection in chronic hemodialysis
26
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
patients and hemodialysis center staff-member. Ann J
Kidney Dec 1993;22(4):568-73.
Pol S, Legendre C. Viral hepatitis in hemodialysis unit 8.
and renal transplantation patient. Nephrology 1994;
15(3):191-5.
Fabrizi F, Marchelli D, Bachini G, et al. Antibodies to 9.
HCV in chronic renal failure patient on conservative
therapy prevalence risk factors and relationship to liver
disease. Nephrol Dial Transplan 1994;9(7):780-4.
Al-Dabry SH. Prevalence of antibodies to HCV among 10.
Omani patients with renal disease. Sultanate of Oman
infection 1993;21(3):146-40.
El-Reshiaid K, Kapoor M, Al-Mufty S, et al. Hepatitis 11.
virus infection in patient with hemodialysis in Kuwait.
Saudi J Kidney Dis Transplant 1995;6(2):144-50.
Al-Muhana Fa. Hepatitis C viral infection among 12.
hemodialysis patient in Eastern Region of Saudi Arabia.
Saudi J Kidney Dis Transplant 1995;6(2):125-27.
Tokar Ji. National surveillance of dialysis associated 13.
disease, center for disease control and prevention,
Atlanta. ASAIO J 1996;43(1):108-19.
Dentico P, Uolope A. Prevalence of hepatitis C virus in 14.
hemodialysis patients, Bari. Italy Clinic Nephron 1992
July;38(1):49-52.
Oquchi H, Miqsala M. HBV, HCV in eleven Japanese 15.
hemodialysis units. Clinical Nephron 1992 July;38(1):
36-43.
Radovic M. Incidence and clinical manifestations of 16.
HCV infection in patients on hemodialysis clinical center
of Serbia. Serb Arth Colok lek 1996;24(1):123-5.
Cassidy MJ, Jan Kelson D. The prevalence of HCV Ab 17.
at two hemodialysis unit in South Africa, SAFR. Med J
1995 Oct;85(10):996-8.
Franceschini N, Gon Calves LE, Prompt CA, et al. Fine 18.
needle aspiration biopsy of the liver in HBsAg positive
patient with end stage renal failure. Renal failure
1994;16(4):491-9.
George J, John GT, Jacob CK, et al. Active immunization 19.
against hepatitis B infection of hemodialysis population.
Natl Med J India 1994 May;7(3):115-6.
Al-Mugeirn M, Al-Faleh FZ, Samia S. Seropositivity to 20.
hepatitis C virus in Saudi children with chronic renal
failure maintained on hemodialysis. Ann Trop Paed
1992;12(2):217-19.
Harrison M, Mooj JM, Roujouleh H, et al. Observation in 21.
Saudi Arabian dialysis population over 13 years period.
Nephron Dial Transplant 1994;9(8):1072-6.
Urbanowics W. HBV infection among selected group of 22.
patients and staff members. Poland Prazgel Epidemiol
1996;50(4):365-70.
Rivanera D. Detection of antibodies to hepatitis C virus 23.
in dialysis patient Rome, Italy. Epidemiol 1993;9(1):
55-8.
El-Shahat Y, Bari M. HCV infection among hemodialysis 24.
patients in United Arab Emirates. Saudi J Kidney Dis
Transplant 1995;6(2):157-62.
Cantu P. Prevalence of antibodies to hepatitis C virus in 25.
dialysis unit. Italy Nephron 1992;61(3):337-8.
Nakashina F. Incidence of antibodies to HCV in patient 26.
undergoing chronic dialysis. Japan Kurume Med J 1993;
40(4):249-53.
Manescalachi F. Anti HCV epidemiological study in 2 27.
centers. Italy Nephron 1992;61(3):342-3.
Silini E. Virological features of HCV infection in 28.
hemodialysis patients. Italy J Clinic Microbial 1993;
31(11):2913-7.
27
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
ABSTRACT
Objective: Although the specicity of the microscopic
method by identifying the LD bodies within the infected
macrophage from the skin lesion was very high, its
sensitivity (30%) remains limited. The purpose of
our study is to work on elevating the sensitivity of the
microscopic method by not only identifying the LD
bodies within the macrophage, but by checking the
amastigote presence in its different cytomorphologies
in both the intra cellular macrophage and the extra
cellular uid of the infected area.
Methods: Thirty seven cases of clinically diagnosed
cutaneous Leishmaniasis were studied after staining
the microscopic slides taken from the presumed infected
area with Wright stain. The study was divided into two
A CYTOMORPHOLOGIC STUDY OF THE DIFFERENT MANIFESTATIONS SEEN
FOR THE AMASTIGOTE FORM IN CUTANEOUS LEISHMANIA
Mohammed Wael Daboul, MD
LD
amastigoteLD
Original Article
*M
28
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
parts: Part one: Dening the different microscopic
cytomorphologies of the amastigote forms and later,
classifying the amastigote forms according to their
common microscopic features into specic classication.
Part two: Studying and calculating the appearance of
the amastigote forms in each and every case in either
the intra or extra cellular uid and comparing them.
Results: The oval in shape and spindle in shape
amastigote types are found in the same rate (43% of the
cases referred), whereas the round shape amastigotes are
present only in 5 % of the cases referred, and the overall
amastigote presence of any type was at about 49% of
all the 37 cases referred to us. Fourty nine percent of
the cases referred show the presence of a smooth and
spreading type of chromatin inside the amastigotes, and
other 49% show the amastigotes with a condensed and
or polarized chromatin in one pole of the amastigote. A
third type of the amastigote is seen with only condensed
chromatin and total absence of the cytoplasm (candle
ame-shape). Overall, the appearance of the amastigote
of any of the mentioned above features constitutes 49%
of the cases referred to us. The amastigote is seen at
41% of the cases referred inside the macrophage, and
46% of the cases referred are having the amastigote
present in the outer cellular compartment. In 38% of the
cases referred to us, the amastigote is shown sharing
both the intra and extra cellular compartments, while
an overall appearance of the amastigote in the cases
referred was 49%.
Conclusions: Our data showed that an additional
20% sensitivity and more specicity is gained by the
microscopic method making the method more competitive
with other procedures and to be considered as the gold
standard method for such leishmaniasis diagnosis.
INTRODUCTION
Since 1996, we followed up the microscopic method
of health hospitals at Saudi Arabia and later here in
method by identifying the LD bodies within the infected
macrophage from the skin lesion was very high, its
1
The purpose of our study is to add more impulse to
the microscopic method by not only identifying the
LD bodies within the macrophage, but by checking the
amastigote presence in its different cytomorphologies in
both the intra cellular macrophage and the extra cellular
LITERATUREREVIEW
Leishmaniasis is an infection caused by a protozoan
parasite belonging to genus Leishmania. The majority
of infections with Leishmania are of the cutaneous
type. Other types include visceral, and mucocutaneous
Leishmania.2
Cases of Leishmaniasis have been reported on every
continent except for Australia. The disease is endemic
in areas in the tropics and subtropics such as Central and
South America, southern Europe, Asia, the Middle East,
world’s population or approximately 350 million people
are at risk of contracting this infection. Worldwide there
are 2 million new cases of Leishmaniasis reported
annually. Moreover, worldwide incidence has increased
over recent years, thought to be related to the AIDS
epidemic, global warming, and other environmental
factors.3
Two forms of the parasite are present, the promastigote
form found in the insect vector and the intracellular
amastigote form found in the vertebrate host.
Amastigotes are spherical in shape, only about
2.5 to 5 µm in diameter, and are contained within a
parasitophagus vacuole within a macrophage. When
seen in a stained blood smear the amastigotes within the
Considering cutaneous leishmania, in peripheral
blood smear the amastigotes are seen inside the
circulating monocytes and neutrophils. Histological
examination of the lesion revealed extensive
clusters of amastigote within histocyte.
29
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
on the isolation of the causative organism by smear and
1
Due to lack of sensitivity of such traditional diagnostic
tests,4,5 some researchers have adopted different
traditional microscopic smear method, an example
leukocyte edge when making a peripheral smear. 2-
By centrifuging citrated blood and withdrawing the
sediment, which then is smeared, dried, and stained.6
Going through the literature above, all the studies
assume the presence of the amastigotes in the intra
cellular space of the macrophage, while our approach
to the smear method presumes the amastigote presence
not only in intra cellular macrophage but in the extra
METHODS
Thirty seven cases of clinically diagnosed cutaneous
Leishmaniasis were sent by consultant dermatologists to
were numerated and couple of slides were taken from
each patient from the infected area.
Samples were collected as follows:
-
1 mm slits through skin to dermis with a scalpel then
scraped the edges to make slide smears, then smears are
and stained with Wright stain.
-Dermal scrapings: We obtained 2-4 scrapings from
different areas of the lesion. We scraped dermis along
the necrotic lip with a scalpel, obtaining as much tissue
as possible, then making thin smears on slide, air dried,
Microscopic photos were taken for the causing
The study was divided into two parts:
Part one:
cytomorphologies of the amastigote forms by identifying
cytomorphology of the amastigotes noticed among all
the cases and later, classifying the amastigote forms
according to their common microscopic features into
tables prepared for that purpose, taking into accounts
the following criteria:
A- The general microscopic shape of the amastigotes
ones are globular in shape and the oval amastigotes are
wider than the spindle in shape-ones, which are thinner
and usually have more dense chromatin inside.
B- The microscopic shape, localization and the
density of the amastigote chromatin.
Part two: Studying and calculating the appearance of
the amastigote forms in each and every case in either the
RESULTS
Table 1 reveals the total count of the amastigotes
appearance in all the cases referred according to each
shape amastigote types are the most predominant in our
the 37 cases referred to us.
Table 2 reveals the total count of the amastigotes
appearance in all the cases referred according to each
smooth and spreading, b-Chromatin condensed and
or polarized, c-Chromatin condensed with cytoplasm
another feature to be considered when looking to the
30
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
show the presence of smooth and spreading type of
or polarized chromatin in one pole of the amastigote
with only condensed chromatin and total absence of
cases referred to us.
Table 3 shows the Amastigote form presence in the
are having the amastigote present in the outer cellular
referred to us, the amastigote is shown sharing both
the intra and extra cellular compartments, while overall
appearance of the amastigote in the cases referred was
DISCUSSION
Most of the investigators for Leishmaniasis have
mentioned in their papers the microscopic method of
diagnosing the leishmania disease. They related on the
presence of the LD bodies within the macrophage as
the standard method for assuming the infection with
the disease. In fact, referring to table 3, we found that
in the extra cellular compartment, the amastigote type
of leishmania is noticed in of the cases referred,
which exceeds the of the cases where we found
the LD bodies within the macrophage. By that,
obviously, researchers missed a considerable number of
cases being considered as falls negative. Our attached
approve clearly such an amastigote
presence. The amastigote presence in the extra cellular
Amastigote form
presence Oval shape Spindle shape Round in shape
Amastigote of any of
the three kinds
# Of cases 16/37 16/37 2/37 18/37
Table 1. Amastigote appearance in reffered cases according to cytomorphologic categories.
Amastigote form
presence
Chromatin smooth
and spreading
Chromatin
condensed and
or polarized
Chromatin condensed with
cytoplasm disappearance
Amastigote of any of
the three kinds
# Of cases 18/37 18/37 15/37 18/37
Table 2. Amastigote appearance in reffered cases according to chromatin morphologic categories.
Amastigote form Intra cellular
amastigote
Extra cellular
amastigote
Amastigote presence in the intra
both locations
Amastigote Present in
both intra and extra cel-
# Of cases 15/37 17/37 18/37 14/37
Table 3.
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JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
compartment can be easily by normally
trained technician and does not require a big effort or
sophisticated instruments to locate it. of
the amastigotes in the extra cellular not only will
add to the method sensitivity but to its as well.
Due to our of the of the cases where
the amastigote has been found both in the intra and extra
cellular compartments, the is elevatedgo
back to table 3
In our research above, of the amastigote
in the extra cellular has added more to the
microscopic test sensitivity and even more to its
.
Going back to table 1 and photos1,2,3,4,5,6,7
attached, it is obvious that there are three different shapes
of the amastigote form, the round, the spindle, and the
oval forms. When locating the amastigotes, whether
inside the macrophage or outside in the , we should
consider the presence of any one of those forms. Our
data in the table declares that the oval and the spindle
shape forms are more present in both the intra and the
extra cellular areas of the infected skin atrate.
Occasionally at rate we come through the round
type of the amastigotes in or outside the macrophage
see photo 2Being able to differentiate and identify
the different forms will add more to the sensitivity of
our microscopic procedure.
Image 1. See the intra cellular amastigotes within the
Depending on the chromatin appearance within the
amastigoteTable 2and photos3,4,5we
the chromatin manifestations into the three mentioned
in the table above. Photos3,4,5 reveal the smooth,
thin chromatin usually spreading in the central location
of the amastigotes, while once the chromatin becomes
more condensed, it assumes a polar position. Both the
shapes are found at the same rate of the cases.
Another interesting feature shown is the chromatin
condensation alone with the cytoplasm disappearance.
It is restricted to the outer cellular and we could
not locate it in side the macrophage. We called itcandle
shapeas a general namePhotos 3,4
Image 2. See the extra cellular amastigote
Image 3. See the three different shapes of the amastigotes
centrally localized smooth and spreading in an oval shape
32
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
It seems that such chromatin manifestation has
something to do with the amastigote life cycle. But
with the amastigote appearance at rate in the outer
cellular which is more than the rate of its
Image 4. See the extra cellular amastigotes according
Image 5. See the extra cellular amastigotes according to
presence in the intracellular macrophagesee table
3It is absolutely clear that such presence in the outer
cellular for the amastigote is beyond the original
facts and all the previous studies indicating that the
leishmania in human is an obligatory intracellular
parasite1.
On applying a new method to the laboratory work
some of the most important roles are:
1- It should be easy to be performed by the general
personal working in the .
2- It should be cost effective.7
Image 6. See the round shape intra cellular
Image 7. See the amastigote distribution and density in
Our add to the microscopic method both the
roles in the best manner.
We recommend the following considerations
to be added to the microscopic procedure and be
implemented:
33
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
1- Consider looking for the amastigote form not only
within the macrophage or the intracellular area but in
the extra cellular as well.
2- Familiarize yourself with the different
cytomorphologies of the amastigote forms and look for
them in the intra and extra cellular space.
3- Be familiar with the chromatin distribution within
the amastigote and thecandle shape
By those recommendations, our data showed that
an additional sensitivity and more are
gained by the microscopic method making it more
competitive with other procedures and to be considered
as the gold standard method for such leishmaniasis
diagnosis.
CONCLUSIONS
Previous studies on Leishmaniasis in general and
cutaneous Leishmania in particular revealed that,
microscopically investigates the presence of only
different shapes of the amastigotes and localizing them
and made the diagnosis of cutaneous Leishmania at
diagnosed, making the smear method more competitive
with other diagnostic procedures.
REFERENCES
Sharquie KE, , 1. Hassen AS, Hassan SA, et al. Evaluation
of diagnosis of cutaneous leishmaniasis by direct
smear, culture and histopathology. Saudi Med J 2002
Aug;23(8):925-8.
Mirzabeigi M, Farook U, Baraiak S, et al. Reactivation 2.
of dormant cutaneous Leishmania infection in a
kidney transplant patient. J Cutan Pathol 2006
Oct;33(10):701-4.
Bern C3. , Magvire JH, Alvar J. Complexities of assessing
the disease burden attributable to leishmaniasis. PloS
Negl Trop Dis 2008 October;2(10):e313.
Faber WR, Oskam L, Van Gool T, et al. Value of 4.
diagnostic techniques for cutaneous leishmaniasis. J Am
Acad Dermatol 2003 Jul;49(1):70-4.
Bensoussan E, Nasereddin E, Jonas F, et al. Comparison 5.
of PCR assays for diagnosis of cutaneous leishmaniasis.
J Clin Microbiol 2006 April;44(4):1435–1439
Vidyashankar C, Ruchir A, Gary JN, et al. Leishmaniasis. 6.
E-Medicine Specialties. Last Updated: February 27,
2006.
Michael L. Bishop, Janet L. Duben-Von Laufen, Edward 7.
P. Fody. Clinical Chemistry: Principles, Procedures,
Correlations. 1st ed. J. B. Lippincott Company; 1985. p.
71-75.
34
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
A PROTECTIVE EFFECTS OF ZN-METALLOTHIONEIN
ON EXPERIMENTALLY INDUCED MYOCARDIAL INFARCTION
AND ARRHYTHMIA IN RABBITS
-
Sobhy AL-Bahri, MD
ABSTRACT
Objective: Zinc-metallothionin is a low molecular weight, zinc binding protein (600-700 Dalton). Metallothionin
has been proposed to participate in the transport, accumulation, and compartmentation of zinc in the biological
system. In addition to its role as a storehouse for zinc, metallothionin acts as a free radical scavenger and protects
against cadmium toxicity. The present work aimed to investigate the possible role of metallothionin in providing a
myocardial protection against isoprenaline-induced myocardial infarction and arrhythmias in rabbits.
Methods: The experiment was performed with 36 male albino rabbits weighing about 1500 g. The animals
were housed in metal cages and provided with breads, vegetables and water. To induce metallothionin formation,
zinc sulfate was injected intraperitoneally 50 mg/kg for three consecutive days. To induce myocardial infarction,
isoprenaline was injected subcutaneously 300 mg/kg, in addition, verapamil was injected intravenously 0.18 mg/kg.
All myocardial infarction indices were evaluated (lactate dehydrogenase (LDH), aspartate aminotransferase (AST)
creatine phosphokinase (CPK)), comparing all groups and ECG was performed.
Results: It was found that metallothionin protected against myocardial infarction as indicated by the lower levels
of creatine kinase, aspertate aminotransferase and lactate dehydrogenase enzymes and improve ECG. It hase also
potentated verapamil effect to protect against tachyarrhythmias.
Conclusions: Injection of zinc sulphate increases Zn-metallothionein and decreases free radicals, so regards as an
antioxidants and improve myocardial infarction.
-
*Sobhy Al-Bahri, MD, Department of physiology, Faculty of Medicine, Damascus University, Syria. E-mail: salbahri@hotmail.com.
Original Article
35
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
LDH AST
INTRODUCTION
ATPase
Na+/+ ATPase
Na+Ca++
SOD
MT
-
Isoprenaline
36
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
ββ
β
verapamil
Ca++
O
LDH
AST
AIMS
METHODS
Sigma Chem.Co.St.Louis
Sigma Chem.Co.St.Louis
SephadexG
AST
LDH
37
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
pH
2.5x50cmG75
BioRa
Isoprenaline HCl
.LDHAST
FC131 FC137
ADP, AMP, diadenosine pentaphosphate, NADP, G-6-
P-DH,N-acetylcysteinecreatine Phosphate, antibody
A1 10
A2
AST
0.1
AST
LDH
LDH
T-test
RESULTS
)(
)( I
250±20.5
II
600±31.8*
+
+
+
38
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
+
BA
C
+
LDH
LDH
+
+
39
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
LDH
AST
AST
+++
+
++
AST
DISCUSSION
beat/min
mm.Hg
U/L
LDH
U/L
AST
U/L
I
320±1560820±23370±449±5
II
318±1660752±18*321±3*40.6±2*
III
320±161820±23370±449.5±5
II+IIIIV
318±1660752±18*321±3*40.6±2*
V
270±17*52±3.5*743±15*309±5*35.6±2*
II+V+IIIVI
245±17*50±4.5*602±25**280.9±9**32.5±1**
TSA
HDL
40
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
ASTLDH
LDH
al
CONCLUSIONS
REFERENCES
Zweier JL, Talukder MA. The role of oxidants and free 1.
radicals in reperfusion injury. Heart and Lung Resea
2006;55:158-75.
Gross GJ, Kersten JR, Warltier DC .Mechanisms of 2.
postischemic contractile dysfunction. Ann Thorac Surg
1999;68:1898-1904.
Pearson PJ, Schaff HV, Vanhoutte PM. Long term 3.
impairment of endothelium-dependent relaxations to
aggregating platelets after reperfusion injury in canine
coronary arteries. Circulation 1990;81:1921-27.
Manning AS, Hearse DJ. Reperfusion-induced 4.
arrhythmias: Mechanisms and prevention. J Mol Cell
Cardio 1984;l16:497-518.
Irani K, Xia Y, Der CJ. Mitogenic signaling mediated 5.
by oxidants in ras-transformed broblast. Science
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Hass ML,Okabe E, Kontos HA. Proton and free oxygen 6.
radical interaction with the calcium transport system
of cardiac sarcoplasmic reticulum. J Mol Cell Cardio
1981;l13:767-72.
Rosen H, Klebanoff J. Hydroxyl radical generation by 7.
polymorphonuclear leukocytes measured by electron spin
resonance spectroscopy. J Clin Inves 1979; 64:1725-9.
Hano O, Thompson-Gorman SL. Coenzyme q10 enhances 8.
cardiac functional and metabolic recovery and reduces
Ca++ overload during posischemic reperfusion. Am J
Physio 1994;266:H2174-H81.
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JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
Dhalla NS, Elmoselhi AB, Makino N. Status of myocardial 9.
antioxidants in ischemia-reperfusion injury. Cardiovasc
Res 2000;47:446-56.
Margoshes M, Vallee BL. A cadmium-binding protein from 10.
equine kidney cortex. J Am Chem Soc 1957;79:4813.
Singh VK, Hanson J. Assessment of metallothionein and 11.
antibodies to metallothionein in normal and autistic
children having exposure to vaccine derived thimerosal.
Pediatr Allergy Immunol 2006;17(4):291-6.
Kagi JHR. Overview of metallothionein. Methods in 12.
enzymology 1991;205:613-26.
Ebadi Hirramatsu M, Burke WJ, Folks DG, et al. 13.
Metallothionein isoforms provide neuroprotection
against 6-hydroxydopamine-generated hydroxyl radicals
and superoxide anions. Proc West Pharmacol Soc
1998;41:155-8.
Palmiter RD. Molecular biology of metallothionein gene 14.
expression. Metallothionein II Exp. Suppl 1987;55:63-
80.
Singh BN. Newer concepts in pathogenesis of myocardial 15.
ischemia: implications for the evaluation of antianginal
therapy. Drugs 1986;32:1.
Barrington PL. Effect of free radicals on 16.
electrophysiological function of cardiac mechanism.
Free-radic Biol Med 1990;1(4):355-65.
Rang HP, Ritter JM, Dale MM. Noradrenergic 17.
transmission. In: Pharmacology, 4th ed. London
Churchill, Livingstone; 2000. p. 875-925.
Harrison’ Anthonys. Fauci. Mc Hill Graw-. Cadiovascular 18.
desiases. Principle of internal medicine. 17th ed. 2008.
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Itoh M, Ebadi M, Swanson S. The presence of zinc-19.
binding proteins in brain. J Neurochem 1983;14:823-
829.
Smeyer-Verbeke J, Defries-Gussenhoven E, Ebinger G, 20.
et al. Distribution of Cu and Zn in human brain tissue
Clin Chem Acta 1974;51:309-14.
Burden DT, Balber LC, Natoff IL. A simple method for 21.
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Pharmacol Ther 1979;5:99-102.
Stein W, Szasz G, Warburg U. Measuring of creatin 22.
kinase. Med Weit 1985;36:572.
Willerson JT, Buja LM. Protection of the myocardium 23.
during myocardial infarction, pharmacologic
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1990;65(19):pp351-411.
Lee H, Goldman L. Serum enzyme assy on diagnosis 24.
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Li S M, Liu B, Liu X L, et al. Effect of metallothionein 25.
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Campbell CA, Kloner PA, Alker KJ, et al. Effect of 35.
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74.
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myocardial apoptosis in copper–decient mice: Role of
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Jianxun W, Elsherif L, Song Z, et al. Cardiac 39.
metallothionein plays the major role in the prevention
of diabetic cardiomyopathy by zinc supplementation.
American Heart Association, Inc 2006;113:544-54.
Kang YJ. The antioxidant function of metallothionein in 40.
the heart. Proc Soc Exp Biol Me 1999;222:263-73.
Cai L. Metallothionein as an adaptive protein prevents 41.
diabetes and its toxicity. Nonlineaity Biol Toxicol Med
2004;2(2):89-103.
43
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
ABSTRACT
Objective: Nasopharyngeal carcinoma (NPC) is
the second leading cancer among men in Sudan. The
objective of this work is to study the demographic and
clinical features of NPC in Sudanese patients and to
compare the results with international series.
Methods: This is a retrospective hospital-based
study conducted at the Institute of Nuclear Medicine,
Molecular Biology and Oncology (INMO), University
of Gezira; Wad Medani, Sudan. Hospital records of all
patients with NPC who presented during the period
from January 2000 to December 2005 were reviewed.
Parameters analyzed were age, sex, ethnic group,
residence and clinical presentation.
Results: The total number of case records reviewed
CLINICAL FEATURES OF NASOPHARYNGEAL CARCINOMA IN SUDAN:
A STUDY OF 103 CASES
MD; Abuidris DO, MBBS; Elgaili EM, MD; El Mustafa OM, MD
.
- -
.
.
Original Article
*Elhaj Abus
*Dafalla Omer Abuidris, Assistant professor, MBBS, Fc Rad-Onc, radiation oncology, Head of Oncology Department, Institute of Nuclear Medicine and Oncol-
ogy, University of Gezira-Wadmedani-Sudan. E-mail: abuidris@yahoo.com.
*Elgaili EM, Assistant professor, MBBS, MD Pathology, Head of Department of Pathology, University of Gezira, Faculty of Medicine, Wadmedani-Sudan.
*El Mustafa OM, Professor of Otorhinolaryngology, MBBS, FRCS, DLO Department of Surgery, Faculty of Medicine, University of Gezira-Wadmedani-
Sudan.
44
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
was 103. Most cases were Gezira State inhabitants
(61.2%). Age distribution ranged from 11 to 82 years
with a mean age of 45.5 years. The male to female
ratio was 2:1. The average duration of symptoms was
16.1 weeks. The most common clinical presentations
in the order of frequency were cervical lymph node
enlargement (73.2%), nasal obstruction (33.9%),
hearing impairment (27.7%), epistaxis (22.3%), ear
pain (18.8%) and palatal paralysis (14.3%). The most
affected ethnic group was Sudanese Arabs (74.8%).
The histological types were WHO-type III in (73.8%) of
patients and WHO-type II in (26.2%) of patients, WHO
type-I was not encountered in this study.
Conclusions: Nasopharyngeal cancer is a common
cancer in Sudan and affects men more than women.
Patients usually present late mostly with cervical
lymphadenopathy and nasal symptoms like obstruction
and epistaxis.
INTRODUCTION
Nasopharyngeal carcinomaNPC has remarkably
distinctive ethnic and geographical distribution.1 NPC
highest incidence in the World is in South-East China,
Hong and Mediterranean basin; on the other
hand, it has low incidence in Europe, Japan and North
America.2,3 It is a disease with great racial and ethnic
variation and this is obvious in Chinese immigrants in
States and . In China, the incidence is
different between different regions.4
The etiology of NPC is associated with genetic and
environmental factors5. Most of nasopharyngeal cancer
is Epstein-Barr virus related, salted is advocated by
Chinese as a risk factor.2,3,6,7 NPC predominately affects
males and most of the patients are in their forth or
decades.8 Histopathologically, NPC is into
three types by the World Health OrganizationWHO
Type I which is keratinizing squamous-cell carcinoma,
WHO-type II which is non-keratinizing epidermoid
carcinoma and WHO-type III which is undifferentiated
carcinomas referred to as lymphoepithelioma or
Schminke tumors.9,10
NPC is characterized by non- presentation.
Most cases present with local disease and/or cervical
lymphadenopathy, approximately of patients
present with cervical nodal metastasis.3,11,12,13 Patients
with nodal metastasis have higher rates of treatment
failure. Symptoms related to primary tumor include
ear pain, nasal speech, hearing loss, trismus and cranial
nerves involvement.14 Larger tumors may cause nasal
obstruction and bleeding. In Sudan, NPC is the leading
cancer in men.15
METHODS
This study was carried out in the Institute of Nuclear
medicine, Molecular Biology and OncologyINMO
which is the second cancer center to be established
in Sudan. This center is to the University of
Gezira in Wadmedani.
A retrospective review of all patients with
nasopharyngeal carcinoma treated at INMO during
the period from January 2000 till December 2005 was
carried out. Parameters reviewed were age, sex, ethnic
group, residence, clinical presentation, histological
types, stage and type of treatment given. SPSS software
was used for data entry and analysis. Results were
tabulated and presented in simple percentage form.
All Sudanese patients who had positive biopsy of
nasopharyngeal cancer during the period of the study
were included. All patients with nasopharyngeal
lymphoma were excluded from this review.
RESULTS
Total number of patients studied was 103, male to
female ratio was 2:1. Age ranged from 11-82 years, with
a mean age of 45.5 years. The main age group affected
was 40-60 years old Figure 1There was no
obvious difference in age groups affected and sex
of the patientsp-value=0.86 Most cases were Gezira
State inhabitantsThe commonest ethnic group
affected was Sudanese of Arab origin other
ethnic groups of African origin constitute.
Clinical presentation: The mean duration of symptoms
was 16.1 weeks, with a range of 4-110 weeks. The
most common clinical presentations in the order of
45
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
frequency were cervical lymphadenopathy
nasal blockage hearing impairment
epistaxisear painand cranial nerves
involvement. Cranial nerves involved in the order of
frequency were; glossopharyngeal abducent
trigeminal facial hypoglossal
occulomotor vagus and optic
nerve Table 1 shows the different symptoms
and the average duration of symptoms before diagnosis.
All cases of positive cervical lymphadenopathy
were diagnosed clinically. Imaging was not a routine
procedure for neck node assessment.
Symptom
Neck swelling 73.2 47.0
Nasal obstruction 33.9 10.0
Hearing impairment 27.7 24.7
Epistaxis 22.3 32.8
Ear pain 18.8 16.0
Trismus 15 4.0
Squint 9.2 22.0
Nasal speech 8 4.0
Facial palsy 8 4.0
Nasal regurgitation 3 4.0
Total 16.1
Table 1. Percentage of symptoms
and mean duration.
Clinical staging: Locally advanced and metastatic
disease was observed in of patients. Locally
advanced disease included all cases with bulky cervical
lymphadenopathy or T4 lesions. All patients with T4
and N3 disease were considered as stage IV according
to the American Joint Committee on CancerAJCC
Figure 2.
Four patients presented with distant metastasis. The
sites of metastasis were the lungs in two patients, the
liver in one patient and bony deposits in one patient. All
patients received radical treatment except those with
distant metastasis.
Histopathology: The dominant histology was WHO
type IIIand WHO type IINo single
case had the WHO type I. No correlation was
found between sex and the disease histologyp=0.87
All patients of less than 20 years age had WHO-III
histology
Figure 1. Age group and percentages of NPC patients.
Figure 2. Clinical staging and percentages with NPC.
DISCUSSION
The diagnosis of NPC is often because of
the nature of its clinical symptoms and
in visualizing the nasopharynx.
The incidence of NPC is low in most parts of the world
less than 1 per 100,0007 In Sudan, NPC accounts for
of all cancer cases according to Sudan cancer
registry and of all cancer cases treated at Radiation
46
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
and Isotopes Center, 16 is the
cancer center to be established in Sudan1967
Although literature from Sub-Saharan Africa is scares,
it is has not been reported that nasopharynx is a common
disease in this region, but Sudan may have high rate of
the disease similar to endemic areas in North Africa.17
NPC is more prevalent in Sudanese males. Higher
incidence rates in males were reported in Denmark and
in North-East of India.8,18,19,20
The pattern of age distribution of NPC varies in
different parts of the world. In Tunisia, bimodal peaks at
the age group of 10-19 years and the age group of 50-59
years were reported. Similar patterns are seen in areas
of intermediate risk like Uganda, and Sudan.21 In
this study no bimodal peaks were noticed. The disease
incidence usually increases at the age group of 13-20
years and reaches a plateau between the age of 40 to 55
years. Such a pattern was reported by Hirayama in India
and Prasad in Malaysia.8,22,23 We couldn’t demonstrate
the previously reported results by Hidayatalla in Sudan,
who demonstrated a peak at the age of 10-19 years.
This may be due to the difference in time and place of
the two studies.16
The types of histology in this series were WHO-II and
WHO-III which is similar to reports from other endemic
areas. High risk populations have larger proportion of
poorly differentiated carcinomasWHO type III24 On
the other hand WHO types II and III were not common
in non-endemic areas. It has been reported in United
States, that the majority of NPC in North America are
WHO type-I keratinizing squamous cell carcinoma
23 No single case in this series presented with
WHO type-I. In this series the neck nodes metastasis is
the commonest presentation, and this is consistent with
international incidence of 60-9011
It is believed that a number of etiological
environmental factors along with genetic/host factors
may be responsible for the causation of NPC. Ho JH,
suggested that at least three etiological factors which
are EBV infection, genetically determined susceptibility
and other associated environmental factors are possibly
contributing for the high incidence of NPC in Chinese
populations.25 Hidayatalla suggested a role of ethnicity
and geographic distribution in causation of NPC, this
series showed no difference between different ethnic
groups or different regions of Sudan. Arabs are the
dominant inhabitants of Gezira region where this study
was conducted. This suggests a possibility of genetic
and environmental factors in the etiology of NPC in
Sudan.
CONCLUSIONS
RECOMMENDATIONS
Nasopharyngeal cancer is a common cancer in
Sudanese and affects men more than women. Sudanese
Arabs are the most affected ethnic group and usually
present late with cervical lymphadenopathy, nasal and
ear symptoms and cranial nerves palsies. The commonest
histological types were WHO type II and III. No single
case of the WHO type I was encountered in this study.
Improving awareness of the public and medical
personnel in Sudan about early symptoms and signs of
NPC would help picking up early stages of the disease.
Cancer-registry is essential for cancer prevention and
control in Sudan. Encouraging studies for screening for
potential risk factors should help in setting preventive
measures for the disease. Further studies to evaluate
treatment modalities, morbidity and mortality are also
recommended.
REFERENCES
Tune CE1. , Liavaag PG, Freeman JL, et al. Nasopharyngeal
brush biopsies and detection of nasopharyngeal cancer
in a high-risk population. J Natl Cancer Inst; 1999;
91:796–800.
Collins2. SL. Squamous cell carcinoma of the oral cavity
and oropharynx. In: Ballenger JJ, Snow JB Jr, (eds).
Otorhinolaryngology: head and neck surgery.15th ed.
Media, Pa: Williams & Wilkins; 1996. p. 249-368.
Vasef3. MA, Ferlito A, Weiss LM. Nasopharyngeal
carcinoma, with emphasis on its relationship to Epstein-
Barr virus. Ann Otol Rhinol Laryngol 1997;106:348-56.
Cheng4. Her. Nasopharayngeal cancer and the Southeast
Asian patient. Am Fam Physician 2001;63(9):1776-
1782.
Levine5. PH, Pocinki AG, Madigan P, et al. Familial
47
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
nasopharyngeal carcinoma in patients who are not
Chinese. Cancer 1992;70:1024–9.
Armstrong6. RW, Imrey PB, Lye MS, et al. Nasopharyngeal
carcinoma in Malaysian Chinese: salted sh and other
dietary exposures. Int J Cancer 1998;77:228-35.
Vokes7. EE, Weichselbaum RR, Lippman SM, et al. Head
and neck cancer. New Eng J Med 1993;328:184-194.
Hirayama8. T. Descriptive and analytical epidemiology of
nasopharyngeal cancer. IARC Sci publ 1978;(20):167-
89.
Vokes9. EE, Liebowitz DN, Weichselbaum RR.
Nasopharyngeal carcinoma. Lancet 1997;350:1087–91.
Farrell10. PJ, Cludts I, Stuhler A. Epstein-Barr virus genes
and cancer cells. Biomed Pharmacother 1997;51:258–
67.
Gasim11. J, Bachouchi M, Cvitkovic E, et al. Nasopharangeal
carcinoma: medical oncology view point: the Gustave
Roussy experience. Ann oncol 1990;1:245-253.
Neel12. HB 3d. Nasopharyngeal carcinoma: diagnosis,
staging, and management. Oncology (Huntingt) 1992;
6:87–95.
Perez13. CA, Devineni VR, Marcial-Vega V, et al. Carcinoma
of the nasopharynx: factors affecting prognosis. Int J
Radiat Oncol Biol Phys 1992;23:271–80.
Altun14. M, Fandi A, Dupuis O, et al. Undifferentiated
nasopharyngeal cancer (UCNT): current diagnostic and
therapeutic aspects. Int J Radiat Oncol Biol Phys 1995;
32:859-877.
Hamad15. HMA. Cancer initiative in Sudan. Ann Oncol
2006;17(8):viii33-viii38.
Hidayatalla16. A, Malik MOA, El Hadi AE, et al. Studies on
nasopharyngeal carcinoma in the Sudan: Epidemiology
and aetiology. Eur J cancer clin oncol 1983;16(6): 705-
710.
Feng B17. , Jalbout M , Ayoub W , et al. Dietary risk factors
for nasopharyngeal carcinoma in Maghrebian countries.
Inter J cancer 2007;121(7):1550-1555.
Cancer18. incidence in Denmark 1996. Copenhagen:
Danish National Board of Health, 1999.
Ho19. JH. Epidemiology of nasopharyngeal carcinoma. In:
Hirayama T (ed). Cancer in Asia. Baltimore University
press; 1976. p. 49.
Kumar20. S, Zinyu R, Singh I.K.K, et al. Studies on
naspharyngeal carcinoma with reference to the North
East region of India. Ann Natl Acad Med Sci (India)
1996; 32:199.
Commoun21. M, Hoerner GV, Mourali N. Tumor of
nasopharynx in Tunisia: And anatomic and clinical study
based on 143 cases. Cancer 1974;33:184.
Prasad U22. , Rampal L. Descriptive epidemiology of
nasopharyngeal carcinoma in Peninsula Malaysia.
Cancer Causes Control 1992;3(2):179-182.
Marks23. JE, Phillips JL, Menck HR. The national cancer
data base report on the relationship of race and national
origin to the histology of nasopharyngeal carcinoma.
Cancer 1998;83:582-88.
Burt24. RD, Vaughan TL, Mcknight B. Descriptive
epidemiology and survival analysis of nasopharyngeal
carcinoma in the United States. Inetr J cancer
1992;52:549-56.
Ho25. JH. AN epidemiology and clinical study of
nasopharyngeal carcinoma. Int J Radiat Oncol Biol
Phys 1978; 4:189.
48
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
one year period (from March 2006 until February
2007). Fifty seven (57) patients, with age between (26-
82) years, complaining of unilateral BPPV randomly
allocated into two groups. The rst group (28 patients)
underwent The Particle Repositioning Maneuver.
The second (control) group (29 patients) was treated
conservatively with anti-vertigo medication without
performing the maneuver. All patients were followed
one week after the presentation.
THE EFFICACY OF THE PARTICLE REPOSITIONING MANEUVER
IN TREATING UNILATERAL BENIGN PAROXYSMAL
Basil M.N.Saeed, MD
BPPV
Epley Maneuver
The Particle RepositioningEpley
Maneuver
2007 2006
BPPV
Epley
Dix-Hallpike
Dix-Hallpike
29
p
BPPV
ABSTRACT
Objective: Epley maneuver is a common procedure in
treating benign paroxysmal positional vertigo (BPPV).
This study is carried out to assess the effectiveness and
the safety of a modied form of Epley maneuver (The
Particle Repositioning Maneuver) in treating unilateral
benign paroxysmal positional vertigo (BPPV).
Methods: This prospective study was done over
Original Article
*Basil M.N.Saeed, MD, E.N.T Specialist and Lecturer, Department of Surgery, College of Medicine,University of Mosul, Iraq. E-mail: bnathir71@yahoo.com.
49
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
Results: In the rst group, 24 out of 28 patients
had improvement of symptoms and disappearance of
nystagmus on immediate post maneuver Dix-Hallpike
test, with immediate success rate of 85.7%. Reassessment
one week later showed similar results. In the control
group, only 11 patients out of 29 had symptoms improved
and negative Dix-Hallpike test after one week, with
improvement rate of 37.9%, p-value<0.001 which is
highly signicant in favor of the maneuver group. No
complications were reported in the maneuver group.
Conclusions: We conclude that this repositioning
maneuver is an effective method to treat BPPV.
INTRODUCTION
most common cause of vertigo of peripheral origin. It is
generally seen in individuals age 40 years and older, with
the highest age distribution between 40-70 years. The
symptoms include sudden attacks of vertigo precipitated
by sitting up, lying down, or turning in bed.1-4
The canalithiasis theory was introduced by Hall,
Ruby and McClure in 1979; they proposed that the
signs and symptoms observed in BPPV were the result
semicircular canal.5 This canalith mass move to a more
dependant position when the orientation of the posterior
like in head hanging position.6
Vestibular suppressant and antiemetic medication
is generally ineffective in BPPV.7 In recent years,
treatment has been greatly enhanced by the introduction
of physical treatment which disperses the canal debris.
The Epley maneuver entails a sequence of movements of
head and trunk to rotate the posterior semicircular canal
in a plane that displaces the plug of debris from the canal
into the utricle of the inner ear, where it is inactive. The
original Epley maneuver is performed with the patient
sedated, with mechanical skull vibration is routinely
used and the patient head is moved sequentially through
5 separate positions.8
position maneuver that eliminates the need for sedation
and mastoid vibration. It is thought to be the procedure
used by most clinicians today.9,10,11
The objective of this study is to assess the effectiveness
and the safety of the particle repositioning maneuver in
which evaluates this method in our locality.
This prospective study was done over one year
Otorhinolaryngology in AL-Jamhori Mosul Teaching
Hospital, and in the private clinic. Their ages were
patients were males. Table 1 shows the age distribution
decade.
Number of patients
21- 30 1
31- 40 6
41- 50 15
51- 60 19
61- 70 14
71- 80 1
>80 1
Total number 57
Table 1. Age distribution of patients.
50
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
All the patients complaining of unilateral BPPV with
positive Dix-Hallpike test with the typical nystagmus
of latency, duration, direction and fatigability. Atypical
cases complaining of positional vertigo with no visible
nystagmus were excluded from the study.
Patients were randomly allocated into two groups,
repositioning maneuver. This maneuver was done in the
following manner:
Step 1: The patient with positive Dix-Hallpike test
was moved from the sitting to lying position with the
head hanging similar to the position of Dix-Hallpike
test and the affected ear was undermost. After the
nystagmus produced during this stage had ceased, the
head was kept for 2 minutes.
Step 2: The head was turned 90 degrees to the
opposite Dix-Hallpike position with the neck was fully
extended.
Step 3: The body and head was rotated 90 degrees
in the same direction of rotation so the head was facing
The transition from step 2 into step 3 took no longer
than few seconds, and the head was kept in this position
patient was seated back again and allowed to rest for a
few minutes. Figure 1 describes the maneuver adopted
in our patients.
Dix-Hallpike test was done immediately after the
procedure to assess the effectiveness of the maneuver.
Cinnarizin 25 mg was given twice daily to the failed
group.
The second group of 29 patients were given
medications in the form of cinnarizin 25 mg twice daily
and this group served as control.
All patients were instructed to avoid sleeping on
their backs or on the affected side for one week, and
instructed to be seen after one week. During the next
visit, all patients underwent Dix-Hallpike test.
RESULTS
and positive Dix-Hallpike test were divided into a test
group of 28 patients who underwent the repositioning
maneuver, and a control group of 29 patients who were
treated conservatively with anti-vertigo medications. In
the test group, immediate post-maneuver re-testing with
Dix-Hallpike showed the test was negative in 24 patients,
while it was positive with vertigo and nystagmus in 4
patients. The immediate success rate of the procedure
they were prescribed cinnarizin 25 mg twice daily.
A: Head is in the Dix-Hallpike position of the affected ear. B: Head in the opposite Dix-Hallpike position.
C: Further turning of the head and body 90 degrees.
Figure 1. The steps of particle repositioning maneuver.
51
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
No complications, like unsteadiness or neck spasm,
were reported. The control group of 29 patients was
treated conservatively without performing the maneuver
and patients were prescribed cinnarizin 25 mg twice
daily.
After one week, 23 patients of the test group came for
follow up including three patients who failed to respond
symptom free with negative Dix-Hallpike test, while
the remaining 3 patients had positive positional test,
and they underwent another repositioning maneuver.
Immediate check by positional testing revealed decrease
in the severity of vertigo and nystagmus in all of them,
they were kept on the same previous medication for 2
weeks. They were reassured and instructed to be seen
on need.
In the second group, all patients came for follow up
after one week. Dix-Hallpike test was still positive in
of the vertigo with negative Dix-Hallpike test after one
to the repositioning maneuver and were kept on anti-
vertigo medications for another week. After one week
only 12 patients of them came for follow up and only
two patients had positive Dix-Hallpike test who were
kept on medication for another 2 weeks. Table 2 and 3
show the clinical summary and results of the test and
control groups respectively.
Number of patients 28
Female: male 1.8:1
Mean age
Success rate
Complications No complications reported
Table 2. Clinical summary and results
in the test group.
Number of patients 29
Female: male 1.9:1
Mean age
Improvement rate
Failure
6
pati
Table 3. Clinical summary and results
in the control group.
Statistic A It is a randomized trial in
which the success of the maneuver in the test group
A: Particles in the posterior canal. B: Movement during step 1 and 2, away from the ampulla toward the crus.
C: When the patient is in step 3: Particles are moving into the vestibule through the crus.
Figure 2. The proposed pathway of the particle movement in PRM.
52
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
these results represent the improved patients after on
week of the presentation.
value after statistical evaluation is found to be less than
of the maneuver group.
DISCUSSION
on the canalith repositioning procedure The
original Epley maneuver is performed with the patient
sedated, with mechanical skull vibration is routinely
used and the patient head is moved sequentially through
5 separate positions. Epley postulated that the procedure
of gravity from the posterior semicircular canal into the
utricle.8
that eliminates the need for sedation and mastoid
vibration. It is thought to be the procedure used by most
clinicians today.9-11
In our study, this maneuver was adopted in the test
group and the result was tested immediately after
Hallpike testing. The immediate improvement rate was
week later. In the control group, the improvement rate
that in 12 patients who came for follow up, symptoms
disappeared and the positional test was negative in 10
patients. This further strengthens the results obtained.
the proposed movements of the endolymphatic debris
No complication was reported in patients treated with
this maneuver. We were mainly concerned with cervical
problems because of the hyperextension position of the
neck during the procedure.
Epley maneuver was deeply investigated and
some studies were reviewed for comparison. Lynn
reassessed one month after the procedure. The success
in the placebo group.12 In a study by Froehling et al,
Epley maneuver was done in 24 patients, and this was
13
Angeli, et al studied 47 senior citizens. Epley was
adopted in 28 patients, and 19 patients were a control
14
Simhadri, et al compared 20 patients who underwent
Epley maneuver to 20 control patients who used placebo
only. After one week all patients were Dix-Hallpike
15
comparable to the mentioned studies above. Besides,
sleeping instructions were given to all patients to avoid
rapid recurrence of symptoms.16
CONCLUSIONS
is an effective and safe method to treat unilateral and
53
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
typical BPPV. Firstly, it saves the need for medications
which is not without certain side effects especially in
the elderly. Secondly, it has an abrupt effect which is
shown by the rapid relief of symptoms and negative
positional test immediately after the procedure. Thirdly,
it is not associated with troublesome side effects or
complications.So this method is recommended as the
REFERENCES
Mohr D. The syndrome of paroxysmal positional vertigo: 1.
A review. West J Med 1986;145(5):645-50.
Van der Velde G. Benign paroxysmal positional vertigo- 2.
Part I: Background and clinical presentation. J Can
Chiropr Assoc 1999;43(1):31-40.
Lee K J. The vestibular system and its disorders. In: 3.
Essential Otolaryngology. 8th ed. USA: McGraw-Hill
Companies; 2003. p. 88-115.
Swartz R, Longwell P. Treatment of vertigo. Am Fam 4.
Physician 2005;71(6):1115-22.
Hall SF, Ruby RR, McClure JA. The mechanics of benign 5.
paroxysmal vertigo. J Otolaryngol 1979;8(2):151-8.
Epley JM. Positional vertigo related to semicircular 6.
canilithiasis. Otolaryngol Head Neck Surg 1995;112(1):
154-61.
Hilton M, Pinder D. Benign paroxysmal positional 7.
vertigo. B M J 2003;326:673.
Epley JM. The canalith repositioning procedure for 8.
treatment of benign paroxysmal positional vertigo.
Otolaryngol Head Neck Surg 1992;107:399-404.
Parnes LS, Agrawal SK, Atlas J. Diagnosis and 9.
management of benign paroxysmal positional vertigo. C
M A J 2003;169(7):681-93.
Pranes LS, Price-Jones RG. Particle repositioning 10.
maneuver for benign paroxysmal positional vertigo. Ann
Otol Rhinol Laryngol 1993;102(5):325-31.
Welling DB, Barnes DE. Particle repositioning maneuver 11.
for benign paroxysmal positional vertigo. Laryngoscope
1994;104(8 pt 1):946-9.
Lynn S, Pool A, Rose D, et al. Randomized trial of the 12.
canalith repositioning maneuver. Otolaryngol Head
Neck Surg 1995;113(6):712-20.
Froehling DA, Bowen JM, Mohr DN, et al. The canalith 13.
repositioning procedure for the treatment of benign
paroxysmal positional vertigo: a randomized controlled
trial. Mayo Clin Proc 2000;75(7):695-700.
Angeli S, Hawley R, Gomez O. Systematic approach to 14.
BPPV in the elderly. Otolaryngol Head Neck Surg 2003;
128(5):719-25.
Simhadri S, Panda N, Raghunathan M. Effecacy of 15.
particle repositioning maneuver in BPPV: a prospective
study. Am J Otolaryngol 2003;24(6):355-360.
Cakir BO, Ercan I, Cakir ZA, et al. Effecacy of 16.
postural restriction in treating benign paroxysmal
positional vertigo. Arch. Otolaryngol Head Neck Surg
2006;132(5):501-505.
54
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
COMPARATIVE STUDY OF ZYGOMATICMAXILLARY BUTTRESSES
OSTEOTOMIES WITH OR WITHOUT MIDPALATAL OSTEOTOMY IN
SURGICALLY ASSISTED RAPID MAXILLARY
EXPANSION BY USING PALATAL DISTRACTOR
Abed yakan, DDS, MSc, PhD; Mahmoud Al-Solayman, DDS, MSc, PhD;
Muhammad Farid Mouakkeh, DDS, MSc
ABSTRACT
Objective: Assessment the efciency of separating zygomaticmaxillary buttresses, with or without
midpalatal suture osteotomy, on shape and size expansion of the maxilla using palatal distractor.
Methods: Fourteen adult patients (ages between 18-25 years and no inborn deformities or congenital
syndromes) with skeletal maxillary narrowness being clinically and radially assessed. The studied sample
is separated to two groups; Group I: seven patients with bilateral zygomaticmaxillary buttress osteotomy,
Group II: the previous procedure was repeated on another 7 patients but with midpalatal osteotomy.
Results: The expansion in group II has V shape vertically and horizontally, but that was not clear in group
I (p=0.03). Also the maxillary width immediately and 6 months after the expansion in group II increased
statistically when compared with group I (p=0.00), and the percentage of skeletal maxillary expansion after
6 months in group I was 26.17%, but it was 61.88% in group II.
Conclusions: We conclude that midpalatal osteotomy affects the shape of expansion and increases the
percentage of skeletal maxillary expansion in adults.
*Abed Yakan, DDS, MSc, PhD, Oral and Maxillofacial Surfeon, Aleppo University, Faculty of Dentistry, Aleppo, Syria.
*Mahmoud Al-Solayman, DDS, MSc, PhD, Orthodontist, Aleppo University, Faculty of Dentistry, Aleppo, Syria.
*Muhammad Farid Mouakkeh, DDS, MSc, Oral and MAxillofacial Surgeon, Aleppo University, Faculty of Dentistry, Aleppo, Syria. E-mail: fareed_omfs@
yahoo.co.uk.
V
p=0.03
p=0.00
Original Article
55
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
26.17
61.88
INTRODUCTION
Lefort -I
Assisted Surgically
SARPEExpansion Palatal Rapid
ExpansionMaxillary Assisted Rapid Surgically
SARME
ILeFort
SARME SARPE
SARME
SARME
Ingram
Isaacson
15,16,17
V
V
Schwarz
SARME
56
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
AIMS
METHODS
14
25-18
PA
AP
7
-
V
PA
Vll
p=
RESULTS
SPSS.v15 T-Test
57
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
V
p=
G2
G1
V
V
7/7 0/7 3/7 4/7
V
JR-JL
p
p
-
6
JR-JL
p
p
58
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
G1
G2
p
NS
G1
G2
P
-
NS
DISCUSSION
SARME
Isaacson
&
Ingram12, Bell & Epker19, Bays & Greco20,
Shetty21 et al14
V
dry skulls Wertz
2004Friedrich23
59
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
Berger24
Friedrich23
10
Friedrich23
10
Babacan25
CONCLUSIONS
V
REFERENCES
1.Silverstein K, Quinn PD. Surgically-assisted rapid palatal
expansion for management of transverse maxillary
deciency. J Oral Maxillofac Surg 1997:55:725-7.
2. Suri L, Taneja P. Surgically assisted rapid palatal
expansion: A literature review. Am J Orthod Dentofacial
Orthop 2008;133:290-2.
3. Handelman CS, Wang L, BeGole EA, et al. Nonsurgical
rapid maxillary expansion in adults: report on 47 cases
using the Haas expander. Angle Orthod 2000;70:129-
44.
4. Handelman CS. Nonsurgical rapid maxillary alveolar
expansion in adults: a clinical evaluation. Angle Orthod
1997;67:291-305.
5. Bell WH, Epker BN. Surgical orthodontic expansion of
the maxilla. Am J Orthod 1976;70:517-28.
6. Starnbach H, Bayne D, Cleall J, et al. Facioskeletal and
dental changes resulting from rapid maxillary expansion.
Angle Orthod 1966;36:152-64.
7. Koudstaal MJ, Poort LJ, van der Wal K, et al. Surgical
Assisted Rapid Maxillary Expansion (SARME); a review
of the literature. Int J Oral Maxillofac Surg 2005;34:709-
14.
8. Bailey LJ, White RP Jr, Proft WR, et al. Segmental LeFort
I osteotomy for management of transverse maxillary
deciency. J Oral Maxillofac Surg 1997;55:728-31.
9. Turvey TA. Maxillary expansion: a surgical technique
based on surgical orthodontic treatment objectives
and anatomical considerations. J Maxillofac Surg
60
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
1985;13:51-8.
10. Koudstaal MJ, Poort LJ, van der Wal K, et al. Stability,
tipping and relapse of bone-borne versus tooth-
borne surgically assisted rapid maxillary expansion;
a prospective randomized patient trial. In: Surgical
Assisted Rapid Maxillary Expansion; surgical and
orthodontic aspects. 1st ed. BalMedia print management
b.v., Schiedam, Netherlands; 2008. p.61-80.
11. Betts NJ, Vanarsdall RL, Barber HD, et al. Diagnosis
and treatment of transverse maxillary deciency. Int J
Adult Orthod Orthognath Surg 1995;10:75-96.
12. Isaacson RJ, Ingram AH. Forces produced by rapid
maxillary expansion I: Forces present during treatment.
Angle Orthod 1964;34:256-60.
13. Isaacson RJ, Wood JL, Ingram AH. Forces produced by
rapid maxillary expansion II. Angle Orthod 1964;34:261-
70.
14. Kennedy JW 3rd, Bell WH, Kimbrough OL, et al.
Osteotomy as an adjunct to rapid maxillary expansion.
Am J Orthod 1976;70:123-37.
15. Bierenbroodspot F, Wering PC, Kuijpers-Jagtman AM,
et al. Surgically assisted rapid maxillary expansion:
a retrospective study. Ned Tijdschr Tandheelkd
2002;109:299-302.
16. Booy A, Dorenbos J, Tuinzing DB. Corticotomie een
chirurgisch aspect van orthodontie. Ned Tijdschr
Tandheelkd 2000;107:213-4.
17. Remmelink HJ. Corticotomie van de bovenkaak:
een andere benadering. Ned Tijdschr Tandheelkd
2000;107:417 (comment 418).
18. Schwarz GM, Thrash WJ, Byrd DL, et al. Tomographic
assessment of nasal septal changes following surgical-
orthodontic rapid maxillary expansion. Am J Orthod
1985;87:39-45.
19. Bays RA, Greco JM. Surgically assisted rapid palatal
expansion: an outpatient technique with long-term
stability. J Oral Maxillofac Surg 1992;50:110-5.
20. Shetty V, Caridad JM, Caputo AA, et al. Biomechanical
rationale for surgical-orthodontic expansion of the adult
maxilla. J Oral Maxillofac Surg 1994;52:742-9.
21. Wertz RA. Skeletal and dental changes accompanying
rapid midpalatal suture opening. Am J Orthod
1970;58:41-66.
22. Byloff FK, Mossaz CF. Skeletal and dental changes
following surgically assisted rapid palatal expansion.
Eur J Orthod 2004;26:403-9.
23. Berger JL, Pangrazio-Kulbersh V, Borgula T, et al.
Stability of orthopedic and surgically assisted rapid
palatal expansion over time. Am J Orthod Dentofacial
Orthop 1998;114:638-45.
24. Babacan H, Sokucu O, Doruk C, et al. Rapid maxillary
expansion and surgically assisted rapid maxillary
expansion effects on nasal volume. Angle Orthodontist
2006;76:66-71.
61
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
ABSTRACT
A case of subacute sclerosing panencephalitis post
measles vaccination in a 12-year old male child after 11
years of measles vaccination is presented and discussed
with literatures review.
INTRODUCTION
rare degenerative disease of central nervous system
causing progressive loss of cerebral function, paralysis,
coma and death. The cause is a persistent measles
described by Dawson in 1933.1
A 12 year old boy referred to Jordan from Yemen for
re-evaluation after being ill for the last 4 months prior
to his admission. His condition started by deterioration
of his school performance characterized by general
cognitive impairment and mood liability; his parents
his speech, later he became ataxic to the point where he
needed to be fully supported when walking and started
to have repeated grandmal convulsions.
during that period he developed decorticate posture and
spasticity and he continued to have convulsions .
His birth history and mile stones all were normal. He
had received measles vaccine at the age of 9 months, he
did not receive MMR vaccine, and there was no history
of fever, rash, head injury or drug ingestion prior
to his illness or in the past. No history of measeles
infection pre and post-measels vaccination. No family
history of similar conditions or mental retardation or
other neurological diseases. On examination, vital signs
were normal, the child was aphasic, with decorticate
posture, his upper and lower limbs were spastic with
POST- MEASLES VACCINATION SUBACUTE
SCLEROSING PANENCEPHALITISSSPE
Amal S. Al-Taheineh, MD
Case Report
*Amal S. Al-Taheineh, MD, Department of Family Medicine, Royal Medical Services, P. O. Box 293- Amman 11821, Jordan.
E-mail: dr_a_briezat@yahoo.com.
62
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
of meningeal irritation, cranial nerves and fundoscopy
were normal and other systemic examination was
normal. His electrolytes, kidney function tests, liver
function tests and urine analysis were all normal. His
CSF analysis showed normal glucose in relation with
IgG, IgM were high and oligoclonal band was positive,
measles hemagglutination inhibition antibodies titer
Brain CT scan was normal, but MRI brain showed
generalized slowing, with bursts of sharp waves over all
the areas at irregular intervals as shown in Figure 1 in
the second clinical stage. Thus the diagnosis of sub acute
status with nursing care, but he unfortunately continued
to deteriorate and became deeply comatose and died
within 6 months due to respiratory illness, no autopsy
was performed.
Figure 1. EEG showed generalized slowing with bursts
of sharp waves overall the areas at irredular intervals.
DISCUSSION
Children with SSPE are more likely to have been
infected with natural measles than vaccine virus. The risk
of SSPE after measles is 4.0 in 100.000 cases compared
to a risk after measles vaccine of 0.14 in 100.000 cases.1
When the disease occurs in vaccinated children, it is
thought to result from a sub clinical measles infection
that occurred before the age of 1 year,2 although there
are cases reported as young as four months and as old
as 52 years, the clinical symptoms and signs usually
observed in children and young adults 6-15 years of
age,3 with average age of onset at 9 years4, a higher
2 Patients initially presents with personality
changes, myoclonic convulsions usually appear after 2
months, these myoclonic jerks disappear during sleep,
but spontaneous speech and movements decrease, with
further progression, extrapyramidal dyskinesia and
spasticity become prominent. Patients may develop
athetosis, chorea, ballismus and dystonic movements.
optic neuritis, retinitis or macular pigment disturbance.
Patients have lived for as short as 6 weeks or as
long as 20 year. In the terminal stage of disease,
decerebrate rigidity with irregular respiration and signs
of hypothalamic instability are seen.1,5 Diagnosis is
in both CSF and serum.
No proven effective treatment is currently available
although several therapeutic trials, intravenous gamma
globulin IVIG, plasmapheresis, alpha and beta interferon
and isoprinosine are underway,3 carbamazepine
is recommended for myoclonus induced falling
episodes6.
One of the most important limitations in treatment of
still reversible. Also treatment available are very costly
and available only at few centers in the world, moreover,
these treatments are not curative and only help in buying
time for these patients.2 Our patient clinical course
myoclonic jerks and absence of periodic complexes
in EEG in the second stage of the illness. Instead, he
developed ataxia which present in few cases2 and he
did not exhibit any ocular or visual manifestation and
unfortunately his illness was fulminant, he died within
six months. This fulminant course may be due to viral
virulence, early exposure to measles vaccine, impaired
his defense mechanisms or concurrent infection with
other viruses.2
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JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
CONCLUSIONS
Although Subacute Sclerosing Panencephalitis is a
rare disease, but the presented child should raise our
awareness of the condition and its possibility in normal
exposure to natural measles or measles vaccination;
although unfortunately, little appears to change the
usual dramatic neurological deterioration.
Shah1. I. Subacute sclerosing panencephalitis Dawson’s
encephalitis Revisited. Pediatric oncall [serial online]
2004 [cited 2004 july 1].
Grag RK2. , Subacute sclerosing panencephalitis. Postg
Med J 2002;78:63-70.
Simsek E3. , Ozturk A, Yavuz C, et al. Subacute sclerosing
panencephalitis (SSPE) associated with congenital
measles infection. Turk J Pediatr 2005;47(1):058-062.
Canadian Paediatric Surveillance Program.1999 Results 4.
1999:26-8.
Waldo E. Subacute sclerosing panencephalitis. In: 5.
Behrman RE (ed). Nelson Textbook of Pediatrics, 14th
edition. Philadelphia, PA: WB Saunders Company;
1992. p.843.
Miller C, Andrews N, Rush M, et al. The epidemiology 6.
of subacute sclerosing panencephalitis in England and
Wales 1990-2002. Arch Dis Child 2004;89:1145-8.
64
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
ABSTRACT
Supernumerary nipple and breast is a relatively
common nding in women and it is subject to the same
diseases as normal breast and nipple. Twenty year-
old unmarried college student, with an asymptomatic
supernumerary breast and nipple, consult for cosmetic
purposes. The histopathological assessment of the
excised breast revealed a focus of Duct Carcinoma
in Situ (DCIS). A review of the pathology of DCIS is
presented and the problem is discussed.
INTRODUCTION
The presence of accessory breast tissue such as
1 Although supernumerary
breasts and nipples are subjected to the same diseases as
normal breast and nipple, patients usually seek advice
when these lesions become unsightly.2
In this paper, we report a case of Duct Carcinoma
histopathological examination of a supernumerary
breast and nipple excised for cosmetic purposes.
CASE
A 20-year-old unmarried college student presented
to the consultation clinic on the 20th of February 2001
complaining of a «swelling» just below her right breast
which had increased remarkably in size over the last
three years. She also admit the presence of a small
«navus» that had been there «since birth». She did not
notice any change in her «navus» and she is consulting
because she feel uncomfortable about the swelling.
Her menarche was at the age of 15 years with a normal
menstrual cycle since that date.
On examination, the right breast hangs slightly higher
than the left breast, a soft swelling is palpable just below
INCIDENTAL CARCINOMA IN SITU ARISING
IN A SUPERNUMERARY BREAST
Mohammed MD; Louay Latif Qasha, MD
Duct carcinoma In situ
Case Report
Teaching Hospital, Baghdad, Iraq. E-Mail kamilm86@yahoo.com.
luay_qasha@yahoo.com.
65
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
her normal right breast with a small brown nodule that
Figure 1. The right breast hangs a little higher
than the left.
There was no tenderness, no palpable masses and
nothing is expressible from that «nipple». The left breast
Figure 2. Her «navus» is very similar to a nipple.
A decision was made to excise the swelling. Surgery
performed on the 26th of February 2001. The whole
assessment and the pathologist reported «a rudimentary
nipple and breast tissue with few developed duct system,
in one section and the margins of the excised specimen
Postoperatively, a base line mammography for both
normal breasts was obtained and was normal. Apart
from regular follow up and frequent reassurance for the
«very worry» patient, no other treatment advised. The
last time the patient had been seen was on the 18th of
November 2005 with no evidence of axillary or local
disease along with clinically normal both breasts.
Figure 3. The excised specimen.
Figure 4. One section showing DCIS
DISCUSSION
puberty.3 This explains the progressive increase in size
the patient noticed in the last three years. Although the
66
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
most common site for supernumerary nipples is just
below the normal breast, the most common site for
supernumerary breast is the lower part of the axilla,
the occurrence of a supernumerary breast just below a
normal breast is very rare.4
Reviewing the literature, although primary carcinoma
had been reported in ectopic axillary breast,5 so does
Paget's disease in a supernumerary nipple,6 ductal
carcinoma in situ is typically diagnosed in asymptomatic
women undergoing screening mammography.7 It is a
pre-invasive cancer that has not reached the epithelial
basement membrane. This was previously a rare, usually
is becoming increasingly common owing to the advent
of mammography screening.8 It rarely presents as a
when excising a benign mass.8 The risk of invasive
with DCIS.9
Incidentally discovered foci of DCIS, during
histopathological examination of excised supernumerary
breast, is a very rare event especially in a young
asymptomatic women.10
Nowadays, most cases of DCIS are detected
mammographically, and the suspected area is localized
by a needle or a wire which is used to locate excision
site.11
imaging is being used for screening.12 Mastectomy can be
considered an optimal treatment for asymptomatic DCIS
of a supernumerary breast which also solve the cosmetic
part of the problem.13 Since the rate of axillary lymph
node metastasis for incidentally or mammographically
wide agreement to omit formal axillary lymph node
dissection in patient with this disease.14
The detection of DCIS in supernumerary breast
in a young woman may be a predictor of high risk of
breast cancer.15 Base line mammography screening for
the normal breast and regular follow up for the patient
is important.15 The psychological impact of such a
problem must be taken in consideration during follow
up. Reassurance is indicated.
CONCLUSIONS
This is a very rare incident and it supports the opinion
that supernumerary breasts and nipples are subject to
the same diseases as normal breast and nipples. Careful
histopathological assessment of excised specimens is of
paramount importance. Follow up of the normal breasts
by mammography screening and clinical examination
is indicated. The psychological impact of such an
event, especially on young patients, must be taken in
consideration during follow up.
REFERENCES
Loukas M, Clarke P, Tubbs RS. Accessory breasts: 1.
a historical and current perspective. Am Surg 2007;
73(5):525-8.
Rooda AK, Hansen JP, Rider JA, et al. Ectopic breast 2.
cancer. Breast J 2002 Sep-Oct;8(5):286-89.
Gilmore HT, Milroy M, Mello BJ. Supernumerary 3.
nipples and accessory breast tissue. SDJ Med 1996
May;49(5):149-51.
Osborne MP. Breast development and anatomy. In: Harris 4.
JR, Lippman ME, Marrow M, et al. (eds). Diseases of the
breast. Philadelphia: Lippincott-Raven; 1996. p. 1-14.
Gutermuth J, Audring H, Voit C, et al. Primary carcinoma 5.
of ectopic axillary breast. J Eur Acad Dermato Venereol
2006 Feb;20(2):217-21.
Martin VG, Pellettiere EV, Gress D, et al. Paget6. ,s disease
in adolescent arising in a supernumerary nipple. J Cutan
Pathol 1994 Jun;21(3):283-86.
Black WC, Nease Jr RF, Tosteson AN. Perception of 7.
breast cancer risk and screening effectiveness in women
younger than 50 years of age. J Natl Cancer Inst
1995;87:720-731.
Lagios MD, Page DL. In situ carcinoma of the breast: duct 8.
carcinoma in situ, paget,s disease, lobular carcinoma in
situ. In: Bland KI, Copeland EM III (eds). The breast:
comprehensive management of benign malignant disease.
Philadelphia: WB Saunders; 1998. p. 216.
Cataliotti L, Distante V, Ciatto S, et al. Intra ductal breast 9.
cancer: review of 183 consecutive cases. Eur J Cancer
1992;28A:917-920.
Evans AJ, Pinder SE, Ellis IO, et al. Screen detected 10.
ductal carcinoma in situ (DCIS), over diagnosis or an
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obligate precursor of invasive disease? J Med Screen
2001;8:149.
Silverstien MJ, Gierson ED, Colburn WJ, et al. Can intra 11.
ductal breast carcinoma be excised completely by local
excision? Clinical and pathological predictors. Cancer
1994;73:2985-89.
Yasuda S, Ide M, Fujii H, et al. Application of positron 12.
emission tomography imaging for cancer screening. Br J
Cancer 2000;83:1607-11.
Schwartz GF. The role of excision and surveillance alone 13.
in sub clinical DCIS of the breast. Oncology (Huntingt)
1994;8:21-26.
Balch CM, Singletrary ES, Bland KI. Clinical decision-14.
making in early breast cancer. Ann Surg 1993;217:207-
225.
Page DL, Steel CM, Dixon JM. Carcinoma in situ and 15.
patient at high risk of breast cancer. In: Dixon JM (ed),
ABC of breast diseases, 2nd ed. London: BMJ Books;
2000. p. 90-96.
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Medical case
A 37-year-old man was referred for evaluation of distal renal tubular acidosis. Laboratory
evaluation revealed a serum potassium level of 3.3 mmol per liter, a bicarbonate level of 16 mmol per
2
of body-surface area. He had been given a diagnosis of renal tubular acidosis at 9 years of age on the
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basis of metabolic acidosis with a high urinary pH and hypokalemia associated with nephrocalcinosis.
At that time, there was evidence of bilateral nephrocalcinosis on plain abdominal radiography. The
patient was treated with sodium bicarbonate and potassium supplementation and had normal growth but
with type 1 distal renal tubular acidosis, in which nephrocalcinosis is present but is limited to the renal
medulla. Three years after sodium bicarbonate and potassium supplementation was restarted, the patient’s
renal function has remained stable.
PTH
PH
..............................................................................................................................................
Andres Serrano, M.D; Daniel Batlle, M.D
Northwestern University Feinberg School of Medicine, Chicago, IL 60611
N Eng J Med 2008 Jul;359(1) Image in clinical medicine
Translated by Samir Aldalati, MD
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*Innate Factors in Human Breast Milk Inhibit Cell-Free
HIV-1 but Not Cell-Associated HIV-1 Infection of CD4+
Cells.
*Genetic Contribution to Patent Ductus Arteriosus in the
Premature Newborn.
*Iron Supplementation of Breastfed Infants From an Early
Age.
*Neuroimmune Interaction and Anorectal Motility
in Children With Food Allergy-Related Chronic
Constipation.
*Humoral Immune Response After Post-Chemotherapy
Booster Diphtheria-Tetanus-Pertussis Vaccine in Pediatric
Oncology Patients.
*Serum Melatonin Levels in Children With Epilepsy or
Febrile Seizures.
*The Role of Iron in the Pathogenesis of Endometriosis.
After Iaparoscopic Staging: Feasibility and Operative
Results.
*Risks for Preterm Delivery and Low Birth Weight
are Independently Increased by Severity of Maternal
Anaemia.
*Ocyte Diameter as a Predictor of Fertilization and Embryo
Quality in Assisted Reproduction Cycles.
*Impact of Omphalocele Size on Associated Conditions.
*A Single-Blinded, Randomized Comparison of
Laparoscopic Versus Open Hernia Repair in Children.
*Outcome After Severe Head Injury: Focal Surgical
Lesions Do not Imply A Better Glasgow Outcome Score
Than Diffuse Injuries At 3 Months.
*What Happens to the External Carotid Artery Following
Carotid Endarterectomy?
*Carotid Artery Structural and Functional Evaluation
in Relatives of Type 2 Diabetic Patients.
*Right-to-Left Shunt With Hypoxemia in Pulmonary
Hypertension.
*Short Term Exposure to Cooking Fumes and Pulmonary
Function.
*Cigarette smoke regulates the expression of TLR4 and
IL-8 production by human macrophages.
*A New Parameter Using Serum Lactate Dehydrogenase
and Alanine Aminotransferase Level is Useful for
Predicting the Prognosis of Patients at An Early Stage of
Acute Liver Injury
*Sleep Posture and Unilateral Renal Stone Formation.
Endocrinology, Metabolism & Diabetes
*Leptin and Endothelin-1 Mediated Increased Extracellular
Matrix Protein Production and Cardiomyocyte Hypertrophy
in Diabetic Heart Disease.
Cancer Cachexia
*The Role of Intraoperative Radiotherapy in Solid
Tumors.
*Impact of Plasma tissue Inhibitor of Metalloproteinase-1
on Long-Term Survival in Patients With Gastric Cancer.
*A Double-Blinded, randomized Controlled Trial of
Zoledronate Therapy for HIV-Associated Osteopenia and
Osteoporosis.
Infectious
*Toxicity of HIV Protease Inhibitors: Clinical
Considerations.
*Regional Block Versus General Anaesthesia for Caesarean
Section and Neonatal Outcomes.
*Emotional Impact in Beta-Thalassaemia Major Children
Following Cognitive-Behavioural Family Therapy and
Quality of Life of Caregiving Mothers.
*Maintenance of Response With Atypical Antipsychotics
in the Treatment of Schizophrenia.
*Clinical Characteristics and Surgical Outcomes of
Pediatric Retinal Detachments With Lens Disorders.
*Evaluation of the in Vitro Skin Permeation of Antiviral
Cream Used to Treat Herpes Simplex Virus Infection
Andrology............................................................
*Oral Tamoxifen Citrate Treatment is More Effective
in Normogonadotropic Patients Who Have Follicle-
Stimulating Hormone Levels Within the Lower Half of
Normal.
*Immunologic Evaluation of Patients With Recurrent Ear,
Nose, and Throat Infections.
*Comparison of Preoperative Computerized Tomography
Scan Imaging of Temporal Bone With the Intra-Operative
Findings in Patients Undergoing Mastoidectomy.
*Sensitivity of Direct Versus Concentrated Sputum Smear
Microscopy in HIV-Infected Patients Suspected of Having
Pulmonary Tuberculosis.
Selected Abstracts
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Public Health
Lyimo MA, et al.
.
Transmission of HIV from mother to child through breast-feeding remains a global health challenge,
particularly in developing countries. Breast milk from an HIV-infected women may contain both cell-free HIV-1 and
cell-associated virus; however, the impact of human breast milk on HIV infection and replication in CD4 cells remain
poorly understood.
In the present study, we evaluated the effects of breast milk in vitro on infection of CD4 cells with cell-
free HIV-1, including effects on HIV-1 receptor expression, reverse transcription, integration, and viral transcription.
Additionally, we evaluated the ability of breast milk to inhibit cell-associated transmission of HIV-1 from infected
CD4 T lymphocytes.
Our results demonstrate that breast milk potently inhibits infection with cell-free HIV-1 in vitro independently
inhibitory effect of breast milk on HIV-1 infection of CD4 cells was lost during extended culture, and direct coculture
of HIV-infected CD4 T lymphocytes with susceptible target cells revealed that breast milk was ineffective at blocking
cell-associated HIV-1 infection.
may be less effective at blocking infection by cell-associated virus.
HIV-1
HIV-1
CD4HIV-1
HIV-1CD4
HIV-1
CD4HIV-1
HIV-1
CD4
CD4HIV-1CD4
HIV-1
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Pediatrics
Bhandari V, et al.
The most common congenital heart disease in the newborn population, patent ductus arteriosus,
The objective of this study was to quantify the contribution of genetic factors to the variance in liability
for patent ductus arteriosus in premature newborns.
premature twins born at < or =36 weeks’ gestational age and surviving beyond 36 weeks’ postmenstrual age. Patent
ductus arteriosus was diagnosed by echocardiography at each center. Mixed-effects logistic regression was used to
of patent ductus arteriosus, and mixed-effects probit modeling was used to quantify the genetic component.
respiratory distress syndrome, patent ductus arteriosus, necrotizing enterocolitis, oxygen supplementation, and
bronchopulmonary dysplasia were comparable between monozygotic and dizygotic twins. We found that gestational
liability for patent ductus arteriosus.
with the effect being mainly environmental, after controlling for known confounders.
≤
Yale
Connecticut
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Ziegler EE, et al.
Am J Clin Nutr
: The study assessed the effect of early iron supplementation of breastfed infants and tested the hypothesis
The prospective, placebo-controlled study involved exclusively breastfed infants who were randomly
foods were allowed at >4 mo. Infants were followed to 18 mo. Blood concentrations of ferritin, transferrin receptor,
hemoglobin, and red cell indexes were determined at bimonthly intervals. Stool consistency and color and feeding
behavior were recorded.
Iron supplementation caused modest augmentation of iron status during the intervention at 4 and 5.5 mo but
not thereafter. Iron supplements were well tolerated and had no measurable effect on growth. One infant developed
Early iron supplementation of breastfed infants is feasible and transiently increases iron status but not
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Borrelli O, et al.
Food allergy is thought to trigger functional constipation in children but the underlying mechanisms
anorectal motility, were studied in children with refractory chronic constipation before and after an elimination diet
for cow’s milk, egg, and soy proteins.
analysis.
: In children with food allergy-related chronic constipation, an increase in both rectal MC density and
aected by the diet.
NF mast cellMC
oligoantigenic
MC-NFMC
NR R
RP R ARP
PNRR
RP RARP
MCRPR
P<0.050NR MC-NF
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MC-NFMCR
RMC-NFMC
RPARPP
MC-NFMC
MC
NF
Cheng FW, et al.
The role of post-chemotherapy booster vaccination in pediatric oncology children remains to be
established. In this randomized controlled study, we studied the effect of immune responses to diphtheria-tetanus-
and rubella antibodies were measured serially in vaccine and control groups. Subsets of circulating lymphocytes
labeled monoclonal antibodies.
antibody titer less than protective level up to 18 months after stopping chemotherapy.
Post-chemotherapy booster vaccinations produced a strong and sustained effect in humoral immunity
against vaccine-preventable infectious diseases.
DTP
Aventis PasDTP
BIgG
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DTPs
Hbs
Guo JF, et al.
To study serum levels of melatonin in children with epilepsy or febrile seizures in order to provide a basis
for the treatment of epilepsy or febrile seizures with melatonin.
Serum melatonin levels decreased in children with epilepsy or CFS. Supplement of exogenous melatonin
might be a promising treatment for epilepsy and febrile seizures in children.
melatonin
ELISA
CFS
SFS
P<0.01
P<0.01P<0.05
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Obstetrics And Gynecology
Endometriosis may cause symptoms including chronic pelvic pain and infertility, and increases
susceptibility to the development of ovarian cancer. Genomic studies have started to delineate the wide array
of mediators involved in the development of endometriosis. Understanding the mechanisms of endometriosis
development and elucidating its pathogenesis and pathophysiology are intrinsic to prevention and the search for
effective therapies.
The present article reviews the English language literature for biological, pathogenetic and pathophysiological
studies on endometriosis. Several recent genomic studies are discussed in the context of endometriosis biology.
Severe hemolysis occurring during the development of endometriosis results in high levels of free heme and
iron. These compounds oxidatively modify lipids and proteins, leading to cell and DNA damage, and subsequently
expression of heme/iron-dependent mediators in endometriosis. The heme/iron-dependent signaling pathway of
discussed.
review summarizes recent advances in the heme/iron-mediated signaling and its target genes, outlines the potential
challenges to understanding of the pathogenesis and pathophysiology of endometriosis, and proposes a possible
novel model.
DNA
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VRARH
Oleszczuk A, et al.
Int J Med Robot 2009 Jan 19.
advantages of a robotic system and eliminates the manipulation of cancer tissue.
The procedure was indicated in patients with cervical cancer stage FIGO IB1 after laparoscopic lymphadenectomy. A
tumour-adapted vaginal cuff was created transvaginally.
para-aortic lympadenectomy was 356 min, the vaginal cuff creation took 43 min and the radical robotic resection 68
min. No uterine manipulator was used. There were no bladder or bowel complications and no conversion to standard
laparoscopy or laparotomy.
: The VRARH technique combines the advantages of the vaginal route and robotic laparoscopic surgery:
tumour contamination is avoided and complications are minimized. This procedure could be superior to techniques
described previously.
VRARH
VRARH
FIGO IB1
VRARH
: To estimate the effect of the severity of maternal anaemia on various perinatal outcomes.
A cross-sectional study.
Labour Ward, Muhimbili National Hospital, Dar es Salaam, Tanzania.
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The haemoglobin of eligible pregnant women admitted for delivery between 15 November 2002 and 15
February 2003 was measured. Data on socio-demographic characteristics, iron supplementation, malaria prophylaxis,
blood transfusion during current pregnancy, and current and previous pregnancy outcomes were collected and
11.0 g/dl; mild--Hb 9.0-10.9 g/dl; moderate--Hb 7.0-8.9 g/dl; and severe--Hb < 7.0 g/dl. Logistic regression analysis
was performed to estimate the severity of anaemia. The following outcome measures were used: preterm delivery
of 1.4, 1.4 and 4.1 respectively for mild, moderate and severe anaemia. The corresponding risks for LBW and VLBW
were 1.2 and 1.7, 3.8 and 1.5, and 1.9 and 4.2 respectively.
The risks of preterm delivery and LBW increased in proportion to the severity of maternal anaemia.
Muhimbili
WHO
Apgar score
>
>VLBW>LBWstillbirth
VLBWLBW
Romão GS, et al.
Fertil Steril 2009 May 5.
quality in assisted reproduction cycles.
Prospective observational study.
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Sector of Human Reproduction of the University Hospital, Faculty of Medicine of Ribeirão Preto, University
Ribeirão Preto from May to October 2007.
MOD assessment.
after ICSI.
on days
The MOD of mature oocytes does not seem to be related to the occurrence of fertilization or to the
developmental quality of human embryos on days 2 and 3 after ICSI.
MOD
São Paulo
Ribeirão PretoICIS
MOD
MOD
metaphase II
MOD BMODA
MOD
MOD
ICIS
Surgery
Omphalocele is often associated with the presence of other congenital anomalies. Case reports have
demonstrated nonclassical associations occurring in smaller omphaloceles. The aim of this study was to determine if
omphalocele defect size correlates with the type of anomalies found.
Patient records at a pediatric hospital were retrospectively reviewed for an 8-year period. Data were
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defect was determined by either physical examination or operative record of repair. Patient cohorts were designated
Intestinal anomalies, including Meckel’s diverticulum and intestinal atresia, were only seen in patients with small
Small omphalocele size correlates with an increased prevalence of associated gastrointestinal anomalies,
a lower prevalence of cardiac anomalies, and a higher predominance of male sex.
Omphalocele
P=0.01
atresia
P
: The role of laparoscopic surgery in pediatric inguinal hernia repair is unclear. We aimed to compare day-
case laparoscopic hernia repair with open repair.
: A prospective, single-blinded randomized study in children aged 4 months to 16 years with unilateral
inguinal hernia was performed. The primary outcome measure was the time to normal daily activities after surgery.
Secondary outcome measures included postoperative pain, time in the operation room, results, and complications.
The median times in the operation room for laparoscopic hernia repair and open repair were 63 and 38 minutes,
respectively. Surgical and cosmetic results were similar at up to 2 years’ follow-up.
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: Recovery and outcome were similar after open repair and laparoscopic hernia repair in children.
Laparoscopic hernia repair was associated with increased theater time and postoperative pain.
Leach P, et al.
J Trauma Manag Outcomes 2009 Apr 3;3:5.
Historically neurosurgeons have accepted head injured patients only in the presence of a mass lesion
requiring surgical decompression. Underpinning this is an assumption that these patients have a better outcome than
patients without a surgical lesion. This has meant that many patients without a surgical lesion have been managed
locally in the referring hospital. However, there is now evidence that treatment of all head injured patients in a
specialist centre leads to improved outcomes. Therefore, we have asked the question: does the presence of a surgical
lesion imply better outcome from severe head injury?.
patients treated at our institution over a two and a half year period. Of 116 patients admitted with an initial Glasgow
The assumption in the past has always been that patients presenting in coma from traumatic diffuse
brain injury will do worse than those that have a mass lesion amenable to surgical decompression. Our series would
suggest that this is not the case and all severely head injured patients should expect similar outcome when cared for
in a neuroscience centre.
97
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GOS
GCS
P
Abbas SM, et al.
BMC Surg 2008 Nov 25;8:20.
The effect of carotid endarterectomy on the patency of the external carotid artery is unknown. We
conducted a retrospective study to evaluate the long-term changes in the external carotid artery following carotid
endarterectomy.
Data was prospectively recorded for all patients who had carotid endarterectomy between 1997 and 2006
in our vascular surgical unit. These patients had follow-up with carotid duplex ultrasound to assess the patency of the
arteries before and after surgery.
: Carotid endarterectomy was performed on 255 occasions in 236 patients over the ten year study period.
Immediate and long-term outcome of carotid endarterectomy is comparable to results at other major centers. Stenosis
Our results of carotid endarterectomy are comparable to other centers. Long-term follow up of the
external carotid artery with duplex scan showed asymptomatic stenosis in a small percentage of patients.
carotid endarterectomy
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Cardiovascular Diseases
Prado SS, et al.
particularly from cardiovascular causes. Since a family history of diabetes, even in non-diabetic subjects, is regarded
as an increased risk of coronary heart disease, the use of approved surrogate markers of early atherosclerosis, specially
of ultrasonic measurements of the carotid arteries, is of vital importance.
and internal carotid arteries measured, using high-resolution B-mode ultrasonography. Both groups had similar
levels.
predictors of the IMT in the LCCA.
: FH+ individuals with no metabolic disorders presented greater IMT of the left common carotid artery
DM2
FH-FH
BMIB
PC
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LCCAIMT
FH
FH
BMIP
IMTLDLCRP
IMT
Vodoz JF, et al.
BMC Cardiovasc Disord 2009 Mar 31;9:15.
To determine whether true RL shunting causing hypoxemia is caused by intracardiac shunting, as classically
considered, a retrospective single center study was conducted in consecutive patients with precapillary PH, with
: Among 263 patients with precapillary PH, 34 patients were included: pulmonary arterial hypertension,
cardiac index, and pulmonary vascular resistance were 45.8 +/- 10.8 mmHg, 2.2 +/- 0.6 L/min/m2, and 469 +/- 275
parameters. Patients’ characteristics did not differ according to the result of contrast echocardiography.
: When present in patients with precapillary PH, RL shunting is usually not related to reopening of patent
foramen ovale, whatever the etiology of PH.
PH
intracardiac
Qs/QtPaO2<10 kPaprecapillary PH
AaPO2O2
COPD
PaO2 -dyn
OAaPO2Qs/Qt
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Qs/Qt12
Pulmonary Diseases
Svedahl S,et al.
: Exposure to cooking fumes may have different deleterious effects on the respiratory system. The aim
of this study was to look at possible effects from inhalation of cooking fumes on pulmonary function.
and were monitored with spirometry four times during twenty four hours, on one occasion without any exposure, and
on another with exposure to controlled levels of cooking fumes.
The change in spirometric values during the day with exposure to cooking fumes, were not statistically
: In our experimental setting, there seems to be minor short term spirometric effects, mainly affecting
FET, from short term exposure to cooking fumes.
BA
spirometry BA
FET FET
FET
P
FET
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8
Sarir H, et al.
of defense against inhaled particles. The importance of those cells in the pathophysiology of chronic obstructive
which can stimulate immune cells to produce reactive oxygen species ROS, cytokines and chemokines.
downregulation could be explained by internalization of the TLR4 and the upregulation by an increase in TLR4 mRNA.
IL-8 mRNA and protein were also increased by CSM. CSM stimulation increased intracellular ROS-production
activation, IkB-alpha degradation, IL-8 mRNA and protein, GSH depletion and ROS production were all prevented
TLR4 may be involved in the pathogenesis of lung emphysema and oxidative stress and seems to be a
TLRs
COPD
ILTLR4CSM
ROS
TLR4CSM
internalization TLR4
ILTLR4 mRNA
ROSCSMCSM
TLR4 mRNA GSH
GSH IL-8 mRNA IkB-alpha
ROS
TLR4
102
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Gastroenterology
ALTLDH
et al.
Although most patients with severe acute hepatitis are conservatively cured, some progress to acute
by disturbance of the hepatic microcirculation, plays a key role in ALF, we hypothesized that the production of serum
discriminate between conservative survivors and fatal patients at an early stage.
symptoms had appeared more than 10 days before admission were excluded from this study. Among those included,
increase in the ALT-LDH index in conservative survivors but not in fatal patients. While the prognostic sensitivity
ALT-LDH index was useful to predict the prognosis of the patients with acute liver injury and should be
helpful to begin preparation for LT soon after admission.
ALF
LDH
LDHALT
LDH LDH ALTALT-LDH
ALT
ALT-LDH>INR
MELD
ALT-LDH
MELDALT-LDH
ALT-LDH
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JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
Urology And Nephrology
Ziaee SA, et al.
Scand J Urol Nephrol
Until now, there has been no hypothesis to explain the aetiology of recurrent unilateral urolithiasis in
stone formers. Previous studies suggested that sleep posture may lead to alterations of renal haemodynamics. The
probable association between sleep posture and unilateral urolithiasis is reported here.
In this prospective cohort study, 38 patients with recurrent unilateral renal stones and 42
healthy controls were studied. Background variables were evaluated using a questionnaire. Sleep posture was re-
corded with a sleep recorder. Unpaired t test, Mann-Whitney test, and chi-squared test were performed as needed and
Although the impact of sleep posture in recurrent unilateral stone formation remains unclear, sleep
posture may play a causative role in promotion of urolithiasis. Although this observation needs further investigation,
-
bility to change routine sleep posture.
0.05P
chi-squaredMann-WhitneyUnpaired t test
=P
-CI =OR
-CI=OR
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Endocrinology, Metabolism, And Diabetes Mellitus
(
Majumdar P, et al.
Diabetes Metab Res Rev 2009 Apr 23.
synthesis and cardiomyocyte hypertrophy, two characteristic features of diabetic cardiomyopathy.
blockers. FN, ET-1, leptin and leptin receptors mRNA expression and FN protein were measured. Myocytes were
also morphometrically examined. Furthermore, hearts from streptozotocin-diabetic rats were analysed.
Glucose caused increased FN mRNA and protein expression in HUVECs and cardiomyocytes hypertrophy
along with upregulation of ET-1 mRNA, leptin mRNA and protein. Glucosemimetic effects were seen with leptin and
blocker bosentan normalized such abnormalities. Hearts from the diabetic animals showed hypertrophy and similar
mRNA changes.
These data indicate that in diabetes increased FN production and cardiomyocyte hypertrophy may be
mediated through leptin with its interaction with ET-1.
FNET-11
FNHUVECs
ET-1
mRNA
streptozotocin
HUVECs
BA
mRNA
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Durham WJ, et al.
Curr Opin Clin Nutr Metab Care
Cancer cachexia is associated with marked alterations in skeletal muscle protein metabolism
signaling and altered amino acid metabolism in cancer.
Loss of skeletal muscle in cancer patients can potentially be due to anorexia and early satiety,
each of these mechanisms. Effects on appetite appear to be mediated by the melanocortin system in the hypothalamus.
Studies in animal models of cachexia suggest that modulation of orexigenic and anorexigenic pathways in this system
ameliorate the net catabolic effect on skeletal muscle protein metabolism. Future studies of the precise mechanism
warranted.
melanocortin
IL
TNF-a
Hematology And Oncology
Skandarajah AR, et al.
Ann Surg Oncol 2009 Jan 14.
Combined multimodality therapy is becoming standard treatment for many solid tumors, but the role of
intraoperative radiotherapy in the management of solid tumors remains uncertain. The aim is to review the indication,
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JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
application, and outcomes of intraoperative radiotherapy in the management of nongynecological solid tumors.
A literature search was performed using Medline, Embase, Ovid, and Cochrane database for studies
between 1965 and 2008 assessing intraoperative radiotherapy, using the keywords “intraoperative radiotherapy,”
“colorectal cancer,” “breast cancer,” “gastric cancer,” “pancreatic cancer,” “soft tissue tumor,” and “surgery.” Only
publications in English with available abstracts and regarding adult humans were included, and the evidence was
critically evaluated.
Our search retrieved 864 publications. After exclusion of nonclinical papers, duplicated papers and exclusion
of brachytherapy papers, 77 papers were suitable to assess the current role of intraoperative radiotherapy. The clinical
application and evidence base of intraoperative radiotherapy for each cancer is presented.
Current studies in all common cancers show an additional in local recurrence rates when
intraoperative radiotherapy is included in the multimodal treatment. However, intraoperative radiotherapy may not
improve overall survival and has morbidity depending on the site of the tumor. Intraoperative radiotherapy
does have a role in the multidisciplinary management of solid tumors, but further studies are required to more
precisely determine the extent of .
:
CochraneOvid Embase Medline
brachytherapy
:
Yoshikawa T, et al.
and metastases.
The plasma TIMP-1 concentration was examined preoperatively in 149 patients with gastric cancer who
underwent a surgical resection. The cutoff value of TIMP-1 was set at 112.5 ng/ml based on a previous report. These
patients were followed up for more than 5 years prospectively.
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with respect to TIMP-1.
These results suggest that plasma TIMP-1 is a strong independent prognosticator for the long-term
survival of patients with gastric cancer.
tissue inhibitor of metalloproteinase-1metalloproteinase-1
TIMP-1
TIMP-1
TIMP-1
TIMP-1
TIMP-1TIMP-1
NTTIMP-1RMNT
TIMP-1
TIMP-1
Rheumatology And Orthopedics
HIV
Huang J, et al.
AIDS
osteopenia and osteoporosis.
A double-blinded, randomized, placebo-controlled, 12-month trial of 5 mg intravenous zoledronate dose to
treat 30 HIV-infected men and women with osteopenia and osteoporosis.
Following zoledronate or placebo infusions, participants were followed for 12 months on daily calcium and
vitamin D supplements. Lumbar spine and hip bone density was assessed at baseline, 6 and 12 months. Biomarkers of
bone metabolism were measured at baseline, 2 weeks, 3, 6, 9, and 12 months. Student’s t-test and repeated measure
analyses were used to evaluate bone density and bone marker changes over time.
receiving placebo.
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JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
with placebo controls. No acute infusion reactions were detected, but one patient developed uveitis, a recognized
complication of zoledronate, which responded to therapy.
In this small study, annual zoledronate appears to be a well tolerated and effective therapy for HIV-
associated bone loss.
zoledronate
HIV
placebo
HIV
zoledronate
Dzoledronate
Student‘s t
T-scoresT
HIV
CD4
antiretroviralRNA-HIV
zoledronate
T
zoledronate
zoledronateuveitis
zoledronate
HIV
Infectious Diseases
HIV
Boesecke C, et al.
Curr Opin HIV AIDS
To review recent studies reporting toxicity, adverse events, side effects, and drug-drug interactions
related to the use of HIV protease inhibitors, with particular focus on possible clinical implications.
Toxicity-associated adverse events still remain a major concern when prescribing HIV protease
inhibitors. Among those, diarrhea, lipid, and liver enzyme elevations are predominant. Also, with protease inhibitors
into account in patients who often require coadministration of drugs to treat supplementary diseases, for example,
toxicities of particular protease inhibitors as well as in comparing them among each other.
Protease inhibitors are still a cornerstone of combination antiretroviral therapy. A profound knowledge
109
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
and well tolerated antiretroviral therapy. Further research will elucidate the potential role of protease inhibitors both
in double-boosted salvage therapy and in resource-limited settings.
HIV
HIV
P450
antiretroviral
Anaesthesia And Intensive Care Medicine
Algert CS, et al.
BMC Med
Anaesthesia guidelines recommend regional anaesthesia for most caesarean sections due to the risk of
failed intubation and aspiration with general anaesthesia. However, general anaesthesia is considered to be safe for
.the foetus, based on limited evidence, and is still used for caesarean sections
anaesthesia were compared with those performed under spinal or epidural, for the outcomes of neonatal intubation
The risk of adverse outcomes was increased for caesarean sections under general anaesthesia for all three
indications and across all levels of hospital. The relative risks were largest for low-risk planned repeat caesarean
deliveries.
The infants most affected by general anaesthesia were those already compromised in utero, as evidenced
by foetal distress. The increased rate of adverse neonatal outcomes should be weighed up when general anaesthesia
is under consideration.
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JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
--
Psychiatry
Mazzone L, et al.
Clin Pract Epidemol Ment Health 2009 Feb 23;5:5.
with beta-thalassaemia major, increasing compliance to treatment, lessening the emotional burden of disease, and
improving the quality of life of caregivers.
Twenty-eight beta-thalassaemic major children that followed CBFT for one year were compared
with twenty-eight age-matched healthy children, focusing particularly on behavioural, mood, and temperamental
standard descriptive statistics.
assessment revealed high emotionality and poor sociability in treated thalassaemic children and in their mothers.
Physical and psychological domains concerning individual’s overall perception of quality of life resulted impaired in
mothers of beta-thalassaemic children.
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JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
CBFT can be a valid tool to increase the compliance with chelation therapy in beta-thalassaemic
children; however, treated children continue to show an important emotional burden; moreover, CBFT therapy seems
not to have any positive impact on the quality of life of caregiving mothers, who may therefore need additional
psychological support.
CBFT
CBFT
chelation
EAS MASCCDI
WHOQOL-BREF
90
CBFT
Stauffer V, et al.
BMC Psychiatry 2009 Mar 31;9:13.
How long an antipsychotic is effective in maintaining response is important in choosing the correct
treatment for people with schizophrenia. This post-hoc analysis describes maintenance of response over 24 or 28
weeks in people treated for schizophrenia with olanzapine, risperidone, quetiapine, ziprasidone, or aripiprazole.
This was a post-hoc analysis using data from 5 double-blind, randomized, comparative trials of 24 or 28
study, time to loss of response in patients who met criteria for response at Week 8 and the proportion of patients
olanzapine rather than comparator to avoid loss of one additional responder over 24 or 28 weeks of treatment was
calculated for each study.
to avoid one additional patient with loss of response with olanzapine versus risperidone, quetiapine and ziprasidone
were favorable, ranging from 5 to 9.
During 24 and 28 weeks of treatment, the antipsychotics studied differed in the time that treated patients
112
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
with schizophrenia remained in response and the proportion of patients who lost response. Olanzapine treatment
risperidone, quetiapine and ziprasidone; but not compared to treatment with aripiprazole.
aripiprazoleolanzapine risperidone quetiapine ziprasidone
28
quetiapinerisperidoneolanzapine
aripiprazole394548ziprasidone
numberneededtotreatNNT
olanzapine
risperidone olanzapine
aripiprazoleolanzapinepziprasidonequetiapine
risperidone quetiapine olanzapine
olanzapineNNT pziprasidone
9-5ziprasidonerisperidonequetiapine
24-28
olanzapine
ziprasidonerisperidone quetiapine
aripiprazole
Ophthalmology
J Pediatr Ophthalmol Strabismus
To describe the clinical characteristics and outcomes of eyes with retinal detachments with lens disorders
and compare them to eyes with retinal detachments without lens disorders.
A retrospective chart review of 42 eyes of 37 children who had retinal detachments with lens disorders
was performed. Eyes were compared based on epidemiological data, characteristics of retinal detachment, and
anatomical and functional surgical outcomes and were then compared to 254 eyes with retinal detachment without
lens disorders.
113
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
and dislocation group compared with cataract and aphakia or pseudophakia groups. In eyes without lens disorders,
intervention.
Pediatric retinal detachment with a lens disorder is associated with unsatisfactory surgical and visual
outcomes compared to those without lens disorders. Primary internal and external approaches are suggested in
children with complicated retinal detachment with lens disorders.
37
42
254
31
5222
9022880202
Dermatology
Hasler-Nquyen N, et al.
BMC Dermatol 2009 Apr 2;9:3.
infections. This study evaluates the in vitro skin permeation and penetration of penciclovir and acyclovir from
After 24 h of cream application, excess cream was washed off and layers of stratum corneum were removed
by successive tape stripping. Amounts of active ingredients having penetrated through the skin were measured, as
well as the amounts in the washed-off cream, in skin strips and creams remaining in the skin. Molecular modelling
was used to evaluate physico-chemical differences between the drugs. Western blot analysis enabled to determine
whether the marker of basal cells keratin 5 could be detected in the various tape strips.
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JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
moieties for acyclovir. Presence of the basal cell marker keratin 5 was underscored in the deeper tape strips from the
skin, giving evidence that both drugs can reach their target cells.
into the deeper epidermis layers, in which it could reach the target basal cells at effective therapeutical concentration.
The small difference in the surface properties between both molecules might also contribute to favour the passage of
penciclovir through the epidermis into the deeper basal cells.
HSV
80sores cold
40
acyclovirpenciclovir
1penciclovir5acyclovir5
24
Westernblot
1penciclovir
acyclovir
1penciclovir
penciclovir
Andrology
FSH
Int Urol Nephrol 2009 Apr 21.
the lower or higher halves of the normal range.
115
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
In this retrospective study, 120 normogonadotropic infertile men with idiopathic
oligozoospermia were included. All patients received 20 mg TC daily as a single dose for 6 months, and semen analysis
and hormone levels were analyzed after 6 months, with the values being compared with those before treatment.
sperm count and concentration compared to the relatively higher FSH group.
This study revealed that initial FSH values can be used as a marker to estimate the probability that a
higher sperm counts after treatment, and it is rational to advise these patients to receive 6 months of oral TC therapy.
double-blind, placebo-controlled, randomized trials.
TC
FSH
tamoxifen citrate
6
TC
TC LH FSH
FSH
FSH
FSHTC
6
ENT
Aghamohammadi A, et al.
Am J Otolaryngol
with history of recurrent or chronic ENT infections, referred by otolaryngologists to the Department of Allergy
enrolled to the study from March 2003 to March 2006. For each patient, demographic information and medical
116
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
histories of any ENT infections were collected by reviewing the patient’s records. We measured immunoglobulin
assay methods, respectively. Of 103 patients, 75 received unconjugated pneumococcus polyvalent vaccine, and blood
each patient using high resolution computed tomography scan.
Long-standing history of ENT infections could be an alarm for ENT infections associated with primary
103
2003
2006
nephelometry IgG
105 75 ELISA
21
ELISA
616103
3IgA
IgG3IgG2IgG
CT
Gerami H, et al.
Saudi Med J
suppurative otitis media CSOM.
In a cross-sectional study, 80 patients with CSOM underwent pre-operative CT scanning and we compared
predictive value of CT scan in tympanic and mastoid cholesteatoma, ossicular chain erosion, tegmen tympani
117
JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
Preoperative CT scan may be helpful in decision-making for surgery in cases of cholesteatoma and
ossicular erosion. Despite of limitations radiological scanning is a useful adjunct to management of CSOM.
CSOM
CSOM
80
mastoidectomyCT
20042000
CT
LSCC
71.3
+
LSCC
CSOM
LaboratoryMedicine
HIV
Cattamanchi A, et al.
BMC Infect Dis
Sputum concentration increases the sensitivity of smear microscopy for the diagnosis of tuberculosis
We performed a prospective, blinded evaluation of direct and concentrated Ziehl-Neelsen smear microscopy
Uganda. Direct and concentrated smear results were compared with results of Lowenstein-Jensen culture.
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JABHS: Journal of the Arab Board of Health Specializations Vol.10, No 2, 2009
Sputum concentration did not increase the sensitivity of light microscopy for TB diagnosis in this HIV-
infected population. Given the resource requirements for sputum concentration, additional studies using maximal
blinding, high-quality direct microscopy, and a rigorous gold standard should be conducted before universally
recommending this technique.
HIV
HIV
61
279
88=p107CI1
64
>pCI
10985=pCI
8999
13=12+1=pCI9510
HIV
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