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REVIEW ARTICLE
Idiopathic CD4 Lymphocytopenia: Spectrum of opportunistic infections, malignancies, and autoimmune diseases
Dina S Ahmad, Mohammad Esmadi, William C Steinmann
April-June 2013, 3(2):37-47
DOI:10.4103/2231-0770.114121  PMID:23930241
Idiopathic CD4 lymphocytopenia (ICL) was first defined in 1992 by the US Centers for Disease Control and Prevention (CDC) as the repeated presence of a CD4+ T lymphocyte count of fewer than 300 cells per cubic millimeter or of less than 20% of total T cells with no evidence of human immunodeficiency virus (HIV) infection and no condition that might cause depressed CD4 counts. Most of our knowledge about ICL comes from scattered case reports. The aim of this study was to collect comprehensive data from the previously published cases to understand the characteristics of this rare condition. We searched the PubMed database and Science Direct for case reports since 1989 for Idiopathic CD4 lymphocytopenia cases. We found 258 cases diagnosed with ICL in 143 published papers. We collected data about age, sex, pathogens, site of infections, CD4 count, CD8 count, CD4:CD8 ratio, presence of HIV risk factors, malignancies, autoimmune diseases and whether the patients survived or died. The mean age at diagnosis of first opportunistic infection (or ICL if no opportunistic infection reported) was 40.7 ± 19.2 years (standard deviation), with a range of 1 to 85. One-sixty (62%) patients were males, 91 (35.2%) were females, and 7 (2.7%) patients were not identified whether males or females. Risk factors for HIV were documented in 36 (13.9%) patients. The mean initial CD4 count was 142.6 ± 103.9/mm 3 (standard deviation). The mean initial CD8 count was 295 ± 273.6/mm 3 (standard deviation). The mean initial CD4:CD8 ratio was 0.6 ± 0.7 (standard deviation). The mean lowest CD4 count was 115.4 ± 87.1/mm 3 (standard deviation). The majority of patients 226 (87.6%) had at least one infection. Cryptococcal infections were the most prevalent infections in ICL patients (26.6%), followed by mycobacterial infections (17%), candidal infections (16.2%), and VZV infections (13.1%). Malignancies were reported in 47 (18.1%) patients. Autoimmune diseases were reported in 37 (14.2%) patients.
  48 8,372 1,074
EDITORIAL
Health care in Syria before and during the crisis
Mazen Kherallah, Tayeb Alahfez, Zaher Sahloul, Khaldoun Dia Eddin, Ghyath Jamil
July-September 2012, 2(3):51-53
DOI:10.4103/2231-0770.102275  PMID:23826546
  46 10,606 1,349
ORIGINAL ARTICLES
Utility of total lymphocyte count as a surrogate for absolute CD4 count in the adult Indian HIV population: A prospective study
Suman S Karanth, NR Rau, Anurag Gupta, Asha Kamath, Vikram Shanbhogue, BC Pruthvi
January-March 2014, 4(1):1-4
DOI:10.4103/2231-0770.127413  PMID:24678463
Background: Standard methods of CD4 counts and plasma viral load estimation require specialized equipment, highly trained personnel and are extremely expensive. This remains a major challenge for the initiation of anti-retroviral therapy for patients in resource-limited settings. Objective: To assess the clinical utility of the total lymphocyte count (TLC) to serve as a surrogate marker for predicting a CD4 counts <350 cell/mm 3 in patients with HIV. Materials and Methods: A prospective study of 200 consecutive newly detected highly active anti-retroviral therapy (HAART) naïve HIV patients admitted over a one year period was conducted. Linear regression, Pearson correlation and receiver operating characteristic (ROC) curves were used to calculate the relationship between TLC and CD4 counts. Results: A significant correlation between TLC and CD4 count was observed (r = 0.682, P < 0.001). TLC cut off of 1200 cell/mm 3 as a predictor of CD4 count <350 cell/mm 3 had 73.1% sensitivity, 100% specificity, 100% positive predictive value (PPV) and 51.4% negative predictive value (NPV). Raising the cutoff to 1500 cells/mm 3 improved the sensitivity to 82.1% with 88.2% specificity, 96.5% PPV, 44.4% NPV. The ROC curve demonstrated highest area under curve (AUC = 0.8) for TLC of 1500 cell/mm 3 . Conclusion: The study showed that TLC cutoff value of 1500 cells/mm 3 was a cost effective surrogate marker for CD4 counts <350 cells/mm 3 in resource-limited settings.
  37 3,789 362
Prevalence of TEM, SHV, and CTX-M Beta-Lactamase genes in the urinary isolates of a tertiary care hospital
Trupti Bajpai, M Pandey, M Varma, GS Bhatambare
January-March 2017, 7(1):12-16
DOI:10.4103/2231-0770.197508  PMID:28182026
Introduction: Extended-spectrum beta-lactamases (ESBLs) are the major cause of resistance to beta-lactam antibiotics such as penicillins, cephalosporins, and monobactams. They are derived from the narrow-spectrum beta-lactamases (TEM-1, TEM-2, or SHV-1) by mutations that alter the amino acid configuration around the enzyme active site. Aim: To determine the prevalence of ESBL (bla TEM , bla CTX-M , and bla SHV ) genes among the members of Enterobacteriaceae. Methodology: The present prospective study was carried out from January 2015 to June 2015 in the Department of Microbiology and Molecular Medicine of a Teaching Tertiary Care Hospital. A total of 526 urine samples were studied. Seventy-eight isolates were subjected to polymerase chain reaction for detection of ESBL genes. Results: In our study, ESBL genes were detected among 18 (45%) phenotypically confirmed ESBL producers and 20 (52.5%) phenotypically confirmed non-ESBL producers. The gene that predominated was bla TEM (48.7%), followed by bla CTX-M (7.6%) and bla SHV (5.1%). Conclusion: Definitive identification of ESBL genes is only possible by molecular detection methods. Phenotypic tests need to be evaluated periodically as their performance may change with the introduction of new enzymes.
  27 4,614 731
REVIEW ARTICLES
Atrial fibrillation post cardiac bypass surgery
Ashraf Mostafa, Mohamed A EL-Haddad, Maithili Shenoy, Tushar Tuliani
July-September 2012, 2(3):65-70
DOI:10.4103/2231-0770.102280  PMID:23826549
Atrial fibrillation occurs in 5-40% patients after coronary artery bypass graft surgery. Atrial fibrillation increases mortality and morbidity in the post-operative period. We sought to conduct a comprehensive review of literature focusing on pathophysiology, risk factors, prevention and treatment of post coronary artery bypass graft atrial fibrillation.
  22 9,352 965
ORIGINAL ARTICLES
Nutritional status as a predictive marker for surgical site infection in total joint arthroplasty
Randa Alfargieny, Zuhir Bodalal, Riyad Bendardaf, Mustafa El-Fadli, Salem Langhi
October-December 2015, 5(4):117-122
DOI:10.4103/2231-0770.165122  PMID:26629466
Background: Surgical site infection (SSI) is considered one of the most serious complications in total joint arthroplasty (TJA). This study seeks to analyze the predictive value of preoperative and postoperative nutritional biomarkers for SSI in elective TJA. Methodology: Nutritional markers were gathered retrospectively utilizing patient's records from the orthopedics department at Benghazi Medical Center (BMC). The sample spanned cases admitted during the 20-month period between January 2012 and August 2013 and had undergone either elective total hip replacement or total knee replacement. The collected lab results included a complete blood count, total lymphocyte count (TLC), and serum albumin (S. alb.) levels. The patients were then divided into two groups based on the occurrence of an SSI. Results: A total of 135 total knee (81.5%, n = 110/135) and total hip (18.5%, n = 25/135) replacements were performed at BMC during the study period. Among these cases, 57% (n = 78/135) had patient records suitable for statistical analysis. The average preoperative TLC was 2.422 ×103 cells/mm3 (range = 0.8–4.7 ×103 cells/mm3) whereas that number dropped after the surgery to 1.694 ×103 cells/mm3 (range = 0.6–3.8 ×103 cells/mm3). S. alb. levels showed a mean of 3.973 g/dl (range = 2.9–4.7 g/dl) preoperatively and 3.145 g/dl (range = 1.0–4.1 g/dl) postoperatively. The majority of TJA patients did not suffer any complication (67.4%, n = 91/135) while eight cases (5.9%) suffered from a superficial SSI. Conclusion: Preoperative S. alb. was identified as the only significant predictor for SSI (P = 0.011). Being a preventable cause of postoperative morbidity, it is recommended that the nutritional status (especially preoperative S. alb.) of TJA patients be used as a screening agent and appropriate measures be taken to avoid SSI.
  16 3,231 743
CASE REPORTS
Nephrotic syndrome after treatment of Crohn's disease with mesalamine: Case report and literature review
Belal M Firwana, Rim Hasan, Walid Chalhoub, Mazen Ferwana, Jin-Yong Kang, Joshua Aron, Joseph Lieber
January-March 2012, 2(1):9-11
DOI:10.4103/2231-0770.94804  PMID:23210014
Inflammatory bowel disease and its various treatments may affect the kidney in several ways. Recently, case reports have been published documenting the development of nephrotic syndrome after the treatment for inflammatory bowel disease with 5-aminosalicylic acid derivatives. We report a 50-year-old patient who was diagnosed with Crohn's disease and was treated with mesalamine. The patient subsequently developed nephrotic syndrome and a renal biopsy showed minimal change disease. He was treated with losartan and rosuvastatin and showed improvement in his renal function and serum cholesterol level. This is the first reported case in Crohn's disease although there have been six previous case reports of nephrotic syndrome following salicylic acid derivatives for ulcerative colitis.
  14 4,682 733
REVIEW ARTICLE
Solitary pulmonary nodule: A diagnostic algorithm in the light of current imaging technique
Ali Nawaz Khan, Hamdan H Al-Jahdali, Klaus L Irion, Mohammad Arabi, Shyam Sunder Koteyar
October-December 2011, 1(2):39-51
DOI:10.4103/2231-0770.90915  PMID:23210008
The solitary pulmonary nodule (SPN) is frequently seen on chest radiographs and computed tomography (CT). The finding of a SPN usually provokes a flurry of clinical and imaging activity as an SPN in at-risk population is an alert signal of possible lung cancer. The frequency of malignant nodules in a given population is variable and depends on the endemicity of granulomatous disease. The percentage of malignant nodules also rises when dealing with at-risk population. The problem is compounded by the fact that with the present generation of CT scanners, 1-2 mm nodules are discovered in approximately half of the smokers aged 50 years or older scanned. A variety of management approaches are applied in the work-up of SPN often requiring evaluation over a long period of time to establish a benign or malignant diagnosis. Comparison with previous imaging studies and morphologic evaluation of the size, margins, and internal characteristics are usually the first step in the evaluation of these nodules. It is often necessary to use additional imaging techniques and occasionally invasive procedures such a percutaneous needle lung or a surgical biopsy. Until recently, the guidelines for follow-up of indeterminate noncalcified nodules detected on nonscreening CT was a minimum of 2 years. However, during the past few years due to further refinements in CT technology and better understanding of tumor behavior, it has prompted a revision of the guidelines of the follow-up of small indeterminate nodules. These guidelines have been endorsed by the Fleischner Society.
  14 49,306 2,271
Western and Islamic bioethics: How close is the gap?
Hassan Chamsi-Pasha, Mohammed Ali Albar
January-March 2013, 3(1):8-14
DOI:10.4103/2231-0770.112788  PMID:23984261
The relation between Islam and medicine has been described as intimate. Muslims are expected to be moderate and balanced in all matters, including health. Islamic law is based on a complete system of morality that can provide a moral context in medicine from a legal perspective. Islamic teaching is also very flexible and adaptable to many new and novel situations. Islamic Ethics also upholds "the four principles" of biomedical ethics proposed by Beauchamp and Childress. Several authors claim that the roots of these principles are clearly identifiable in Islamic teachings. However, there are some differences in the applications of these principles. This article shed light on the roots of the four principles in Islamic teachings and elaborates on the differences between Islamic and contemporary western bioethics.
  14 5,867 696
Prophylactic mastectomy for the prevention of breast cancer: Review of the literature
Rawan K Alaofi, Mohammed O Nassif, Marwan R Al-Hajeili
July-September 2018, 8(3):67-77
DOI:10.4103/ajm.AJM_21_18  PMID:30090744
The high incidence and recurrence rate of breast cancer has influenced multiple strategies such as early detection with imaging, chemoprevention and surgical interventions that serve as preventive measures for women at high risk. Prophylactic mastectomy is one of the growing strategies of breast cancer risk reduction that is of a special importance for breast cancer gene mutation carriers. Women with personal history of cancerous breast lesions may consider ipsilateral or contralateral mastectomy as well. Existing data showed that mastectomy effectively reduces breast cancer risk. However, careful risk estimation is necessary to wisely select individuals who will benefit from preventing breast cancer.
  13 4,973 714
ORIGINAL ARTICLES
Precipitating factors, outcomes, and recurrence of diabetic ketoacidosis at a university hospital in Damascus
Zaynab Alourfi, Hakam Homsi
January-March 2015, 5(1):11-15
DOI:10.4103/2231-0770.148503  PMID:25625084
Aims : To study precipitating factors, outcomes, and recurrence of diabetic ketoacidosis (DKA) at a University hospital at Damascus, the capital of Syria. Patients and Methods : Medical records between 2006 and 2012 were reviewed. One hundred and fifteen admissions for 100 patients with DKA were included. All fulfilled the American Diabetic Association DKA diagnostic criteria. Results: Of 115 admissions of DKA, there were 92 single admission and 23 recurrent admissions (eight patients). The order of precipitating factors of recurrent DKA or single admissions were the same with different percentage. The first and second factors were infection (74% and 48%) and treatment problems (17% and 24%), respectively.Complications rate was significantly higher in the intensive care unit (41.6%), compared to the ward admissions (14.2%). Overall in-hospital mortality rate was 11.3%. The severity of medical conditions that provoke DKA with aging, not the metabolic complications of hyperglycemia or ketoacidosis, were behind this high mortality rate. Patients who died were significantly (P = 0.004) older than patients who were discharged alive. Conclusion: Results concerning precipitating factor were similar to the results of many other studies. However, mortality rate was higher which might be explained by the severity of underlying precipitating illness.
  11 5,565 525
REVIEW ARTICLE
Oral manifestations of Parry-Romberg syndrome: A review of literature
Nader A Al-Aizari, Saleh Nasser Azzeghaiby, Hashem Motahir Al-Shamiri, Shourouk Darwish, Bassel Tarakji
April-June 2015, 5(2):25-28
DOI:10.4103/2231-0770.154193  PMID:25878963
Parry-Romberg syndrome (PRS) or progressive facial hemiatrophy is a developmental craniofacial disorder of unknown etiology characterized by a slowly progressive unilateral facial atrophy. It is associated with different systemic manifestations particularly, maxillofacial, neurologic and ophthalmologic abnormalities. Dentists must be aware of PRS to identify this invalidating disorder. In this article, we review the etiology, clinical features (especially craniofacial and dental manifestations) and treatment of PRS. We searched in PubMed line using specific words such as PRS from 2008 to 2014 (August). We identify 14 papers have described oral manifestations of this syndrome. We excluded all the article papers that did not indicate to oral manifestations of PRS.
  11 4,662 496
Basics of cytology
Mousa A Al-Abbadi
July-September 2011, 1(1):18-28
DOI:10.4103/2231-0770.83719  PMID:23210005
This overview is intended to give a general outline about the basics of Cytopathology. This is a field that is gaining tremendous momentum all over the world due to its speed, accuracy and cost effectiveness. This review will include a brief description about the history of cytology from its inception followed by recent developments. Discussion about the different types of specimens, whether exfoliative or aspiration will be presented with explanation of its rule as a screening and diagnostic test. A brief description of the indications, utilization, sensitivity, specificity, cost effectiveness, speed and accuracy will be carried out. The role that cytopathology plays in early detection of cancer will be emphasized. The ability to provide all types of ancillary studies necessary to make specific diagnosis that will dictate treatment protocols will be demonstrated. A brief description of the general rules of cytomorphology differentiating benign from malignant will be presented. Emphasis on communication between clinicians and pathologist will be underscored. The limitations and potential problems in the form of false positive and false negative will be briefly discussed. Few representative examples will be shown. A brief description of the different techniques in performing fine needle aspirations will be presented. General recommendation for the safest methods and hints to enhance the sensitivity of different sample procurement will be given. It is hoped that this review will benefit all practicing clinicians that may face certain diagnostic challenges requiring the use of cytological material.
  11 16,850 1,312
ORIGINAL ARTICLES
Research productivity in Syria: Quantitative and qualitative analysis of current status
Maria M Diab, Rokana M.O Taftaf, Mohammad Arabi
July-September 2011, 1(1):4-7
DOI:10.4103/2231-0770.83716  PMID:23210002
Context: Scientific research output measured by the number and quality of publications reflects the research productivity of a certain community. Aims: To examine the quantity and quality of research produced by Syrian institutions with particular emphasis on the clinical and biomedical research. Settings and Design: Retrospective observational analysis of research originating from Syrian institutions indexed by Medline and Science Citation Index (SciVerse) Scopus bibliographic databases. Materials and Methods: Comprehensive review of the literature indexed by Medline and SciVerse was conducted including data from Jan 01, 1980 till February 2011 searching for authors affiliated with Syrian institutions. Clinical and biomedical research data were further analyzed quantitatively and qualitatively. Results: The total of manuscripts indexed by SciVerse originating from Syrian institutions during the last 3 decades is 3540. A total of 458 publications cover clinical and biomedical subject areas. The quality of these 458 publications was evaluated by the citation frequency and impact factor of publishing journals with h-index of 24. Conclusions: Although the spectrum of research originating from Syrian institutions is broad, the overall number of publications particularly in clinical and biomedical subjects is minuscule and of limited quality. The presented data indicate the need to promote research capabilities and to bridge the gap in research productivity by Syrian institutions.
  10 5,365 721
REVIEW ARTICLES
Nocturnal enuresis: A topic review and institution experience
John Michael DiBianco, Chad Morley, Osama Al-Omar
October-December 2014, 4(4):77-86
DOI:10.4103/2231-0770.140641  
The objective is to provide a review of nocturnal enuresis (NE), including its epidemiology, etiology, pathophysiology, evaluation, and current management. We also set to provide further insight on the treatment of this condition from the experience derived from patients cared for at our tertiary-care institution. NE affects approximately 15% of all children at 5-year-old, affecting boys more frequently than girls. At our large university tertiary pediatric urology center, NE and incontinence, in general, is one the most common chief complaints prompting urologic care. In this review, we examine the condition in detail, highlighting specific goals of the initial evaluation and treatment. We contrast the commonly implemented treatment recommendations, available from the literature with strategies we have found valuable from our extensive experience in treating patients with this disorder. Using current urologic reference textbooks, book chapters, Medline, journal articles and reviews describing the many aspects of NE were reviewed in order to describe NE and the current practices at our institution. Although, this is not a systematic literature review, it includes relevant available research, institutional experience and urological expert opinion and current practices at a tertiary state health facility. The treatment of NE remains a challenge for many pediatricians and pediatric urologists. This likely stems from the multiple possible etiologies of the disorder. We have established a treatment algorithm at our institution, which we have found successful in the majority of our patients. This consists of starting patients on urotherapy, then offering both the enuresis alarm device and medication therapy as first line treatments, and finally adding anticholingerics for combination therapy. Our hope is with further research the treatment of NE will continue to improve.
  10 6,768 9,517
CASE REPORT
Necrotizing fasciitis caused by Aeromonas caviae
Simit Kumar, Prabir Mukhopadhyay, Mitali Chatterjee, Manas K Bandyopadhyay, Maitreyi Bandyopadhyay, Tapashi Ghosh, Debopriyo Samaddar
October-December 2012, 2(4):94-96
DOI:10.4103/2231-0770.110740  PMID:23826556
Aeromonads are rarely associated with human intestinal and extra-intestinal diseases and syndromes, ranging from relatively mild illnesses such as acute gastroenteritis to life-threatening conditions, including septicemia, necrotizing fasciitis, and myonecrosis. Among the aeromonas species known to cause human infection, Aeromonas caviae has been associated with septicemia and only one reported case of human soft tissue infection. Most of the infections due to aeromonas occur in immunocompromised patients. Herein we describe a successfully treated case of post-traumatic skin and soft-tissue infections due to A. caviae in an otherwise immunocompetent individual.
  9 3,643 539
CASE REPORTS
Testicular adrenal rest "tumor" or Leydig cell tumor? A report of a challenging case with literature review
Hiba Hassan Ali, Alaa Samkari, Haitham Arabi
January-March 2013, 3(1):15-19
DOI:10.4103/2231-0770.112789  PMID:23984262
Congenital adrenal hyperplasia (CAH) refers to group of inherited diseases resulting from impaired adrenal steroidogenesis, and its most common cause is 21-hydroxylase deficiency. Testicular adrenal rest tumors (TARTs) are an important complication of CAH, which probably develop from ectopic remnants of intra-testicular adrenal tissue stimulated by Adrenocorticotropic hormone (ACTH) hypersecretion. These lesions are typically located within the rete testis and are bilateral, synchronous, nodular and multiple. TART usually, but not always, responses to suppressive medical therapy. TART leads to testicular structural damage, spermatogenesis disorders, infertility and most importantly, mass-forming lesions that could be mistaken for Leydig cell tumor (LCT). The later has a significantly different behavior with up to 10% of being malignant. Nowadays, due to advances in diagnosing and treating CAH, mass-forming TART is rarely encountered. As a result, there is the paucity in the medical literature regarding its features from pathological perspective. We herein present a case of mass-forming TART and we discuss the clinical, radiological, and morphological features as well as the major differential diagnosis of this rare lesion.
  9 7,074 702
EDITORIALS
Evaluation report of health care services at the Syrian refugee camps in Turkey
Zaher Sahlool, Abdul Ghani Sankri-Tarbichi, Mazen Kherallah
April-June 2012, 2(2):25-28
DOI:10.4103/2231-0770.99148  PMID:23210017
  9 7,409 1,209
ORIGINAL ARTICLE
Etiology and management of esophageal impaction in children: A review of 11 years
Baraa Alabd Alrazzak, Awni Al-Subu, Yoram Elitsur
April-June 2013, 3(2):33-36
DOI:10.4103/2231-0770.114113  PMID:23930240
Introduction: Esophageal impaction in children is a medical emergency that needs an immediate medical attention. In the last years multiple objects have been detected and were removed endoscopically. In the last decade, Eosinophilic Esophagitis (EoE) has been associated with esophageal stenosis, leading to esophageal impaction with various objects including toys, food, coins and other. Aim: To determine the various objects and symptoms associated with impactions and to develop algorithm that guides Emergency Department Physicians and Primary care Providers when facing such problem in pediatric patient. Material and Methods: A retrospective chart review of all children referred to the pediatric gastroenterology service at Marshall University for FB impaction between 2000 and 2010 was performed. Foreign bodies treated by other specialties were excluded from this review. Clinical and demographic data were retrieved. Results: A total of 291 charts with the diagnosis of foreign body reviewed of which only 126 met the inclusion criteria and considered for final calculation. Male/Female ratio and mean age were 1.17:1.0, and 3.65 ± 0.75 years, respectively. Time of impaction before ER evaluation was: < 24hrs in 75 patients, >24hrs in 17 and in 34 the time of ingestion was not known. Radiology was performed in 118 patients, of whom 1 had pneumo-mediastinum and 1 had pneumothorax. Endoscopic localization of the objects showed: 81- proximal, 23- middle esophagus, and 22- in the distal esophagus. The esophageal mucosa showed non-specific changes in 37 patients, 5 with EoE features, 1 patient with hiatal hernia, 1 patient with candidiasis, and in 5 pts had no mucosal description. Conclusion: Children with foreign body in the esophagus are commonly seen in our Hospital ER. Those children may harbor undiagnosed medical conditions that will need future therapy. Careful endoscopic assessment with mucosal biopsies is needed to diagnose those conditions earlier. Referral to a GI specialist may be warranted.
  9 3,408 456
ORIGINAL ARTICLES
Tissue plasminogen activator versus heparin for locking dialysis catheters: A systematic review
Belal M Firwana, Rim Hasan, Mazen Ferwana, Joseph Varon, Aaron Stern, Umesh Gidwani
October-December 2011, 1(2):29-34
DOI:10.4103/2231-0770.90913  PMID:23210006
Background and Objectives: Hemodialysis catheters are commonly used when renal replacement therapy is initiated. These catheters have significant complications. Among "locking" solutions used in an attempt to decrease these complications is recombinant tissue plasminogen activator (rt-PA). This systematic review is to determine the efficacy of rt-PA versus heparin, the standard of care. Materials and Methods: A systematic review of randomized controlled trials studying rt-PA alone or rt-PA plus heparin versus heparin alone as locking agents for hemodialysis catheters, which included patients needed a temporary hemodialysis catheter for hemodialysis. We identified relevant trials through electronic databases and correspondence with experts. Two investigators independently reviewed potentially eligible trials and extracted data. Results: Three trials met the inclusion criteria. One trial reported an improved catheter malfunctioning in patients using rt-PA plus heparin to lock catheters (20.0%) versus heparin alone (34.8%). Another trial reported higher blood flow rate in hemodialysis catheters in patients who received rt-PA (231.6 ± 12.4 mL/min) compared with those who received heparin (206.9 mL/min). The third trial reported formation and weight of clots which were decreased by half in rt-PA group versus heparin group. Conclusions: In the few randomized trials that met our inclusion criteria, the use of rt-PA as a locking solution for hemodialysis catheters seems to be associated with fewer adverse events and catheter malfunctioning as compared with heparin. Our systematic review is limited by the few randomized trials addressing our question and the wide variety of outcome measures. Further prospective randomized trials are needed to confirm this conclusion.
  9 7,866 10,415
Use of ventilator associated pneumonia bundle and statistical process control chart to decrease VAP rate in Syria
Reem Alsadat, Hussam Al-Bardan, Mona N Mazloum, Asem A Shamah, Mohamed F. E. Eltayeb, Ali Marie, Abdulrahman Dakkak, Ola Naes, Faten Esber, Ibrahim Betelmal, Mazen Kherallah
October-December 2012, 2(4):79-83
DOI:10.4103/2231-0770.110736  PMID:23826553
Objective: Implementation of ventilator associated pneumonia (VAP) bundle as a performance improvement project in the critical care units for all mechanically ventilated patients aiming to decrease the VAP rates. Materials and Methods: VAP bundle was implemented in 4 teaching hospitals after educational sessions and compliance rates along with VAP rates were monitored using statistical process control charts. Results: VAP bundle compliance rates were steadily increasing from 33 to 80% in hospital 1, from 33 to 86% in hospital 2 and from 83 to 100% in hospital 3 during the study period. The VAP bundle was not applied in hospital 4 therefore no data was available. A target level of 95% was reached only in hospital 3. This correlated with a decrease in VAP rates from 30 to 6.4 per 1000 ventilator days in hospital 1, from 12 to 4.9 per 1000 ventilator days in hospital 3, whereas VAP rate failed to decrease in hospital 2 (despite better compliance) and it remained high around 33 per 1000 ventilator days in hospital 4 where VAP bundle was not implemented Conclusion: VAP bundle has performed differently in different hospitals in our study. Prevention of VAP requires a multidimensional strategy that includes strict infection control interventions, VAP bundle implementation, process and outcome surveillance and education.
  9 6,884 9,857
REVIEW ARTICLES
Chronic ankle instability: Current perspectives
Omar A Al-Mohrej, Nader S Al-Kenani
October-December 2016, 6(4):103-108
DOI:10.4103/2231-0770.191446  PMID:27843798
Ankle sprain is reported to be among the most common recurrent injuries. About 20% of acute ankle sprain patients develop chronic ankle instability. The failure of functional rehabilitation after acute ankle sprain leads to the development of chronic ankle instability. Differentiation between functional and anatomical ankle instability is very essential to guide the proper treatment. Stability testing by varus stress test and anterior drawer test should be carried out. Subtalar instability is an important pathology that is commonly by passed during the assessment of chronic ankle instability. Unlike acute ankle sprain, chronic ankle instability might require surgical intervention. The surgical and conservative management options can be very much developed by in-depth knowledge of the ankle anatomy, biomechanics, and pathology. Anatomical repair, augmentation by tendon, or both are the basic methods of surgical intervention. Arthroscopy is becoming more popular in the management of chronic ankle instability.
  9 7,633 2,876
CASE REPORTS
An unusual cause of abdominal pain in a male patient: Endometriosis
Fadi I Jabr, Venk Mani
October-December 2014, 4(4):99-101
DOI:10.4103/2231-0770.140660  PMID:25298953
A rare case of abdominal pain secondary to endometriosis in a 52-year-old man with cirrhosis is presented. The patient had a repair of recurrent inguinal hernia 7 months prior to presentation. An exploratory laparotomy revealed a 4.5 cm × 2.5 cm cystic mass attached to the urinary bladder and the inguinal area. The mass pathology showed a cystic lumen of diameter of 1. 5 cm filled with old blood and surrounded by thick muscular mass. Microscopically, the lesion consisted of thick smooth muscle fibers that concentrically surround a central lumen that is bordered by endometrium such as glands and stroma. Immunostains were positive for estrogen receptors and progesterone receptors in the glandular component and for CD10 in the stroma, which is consistent with endometriosis.
  8 11,283 778
ORIGINAL ARTICLE
Characteristics and outcome of critically ill patients with 2009 H1N1 influenza infection in Syria
Reem Alsadat, Abdulrahman Dakak, Mouna Mazlooms, Ghasan Ghadhban, Shadi Fattoom, Ibrahim Betelmal, Nabil Abouchala, Mazen Kherallah
April-June 2012, 2(2):34-37
DOI:10.4103/2231-0770.99156  PMID:23210019
Objectives: To describe the epidemiologic characteristics, clinical features, and outcome of severe cases of 2009 H1N1 influenza A infections who were admitted to the intensive care units (ICUs) in Damascus, Syria. Materials and Methods: Retrospectively, we collected clinical data on all patients who were admitted to the ICU with confirmed or suspected diagnosis of severe 2009 H1N1 influenza A with respiratory failure at 4 major tertiary care hospitals in Damascus, Syria. Acute Physiology and Chronic Health Evaluation (APACHE) II system was used to assess the severity of illness within the first 24 h after admission. The outcome was overall hospital mortality. Results: Eighty patients were admitted to the ICU with severe 2009 H1N1 infection. The mean age was 40.7 years; 69.8% of patients had ≥1 of the risk factors: asthmatics 20%, obesity 23.8%, and pregnancy 5%; and 72.5% had acute lung injury or adult respiratory distress syndrome, 12.5% had viral pneumonia, 42.5% had secondary bacterial pneumonia, and 15% had exacerbation of airflow disease. Mechanical ventilation was required in 73.7% of cases. The mean hospital length of stay was 11.7 days (median 8 days, range 0-77 days, IQR: 5-14 days). The overall mortality rate was 51% for a mean APACHE II score of 15.2 with a predicted mortality of 21% (standardized mortality ratio of 2.4, 95% confidence interval: 1.7-3.2, P value < 0.001). Conclusion: Critically ill patients with severe 2009 H1N1 infection in this limited resource country had a much higher mortality rate than the predicted APACHE II mortality rate or when compared with the reported mortality rates for severe cases in other countries during 2009 H1N1 pandemic.
  7 4,059 521
REVIEW ARTICLE
Obstructive sleep apnea-hypopnea syndrome: Etiology and diagnosis
Abdul Ghani Sankri-Tarbichi
January-March 2012, 2(1):3-8
DOI:10.4103/2231-0770.94803  PMID:23210013
Sleep disordered breathing is a common chronic condition in the general population. This review will highlight the prevalence of different types of sleep apnea in general and obstructive type in particular in the United States and Middle East. Despite the extensive research studies on the sleep apnea pathogenesis, the exact mechanism is not well known. Obesity, however, is the leading risk factor to upper airway narrowing and obstruction and main contributor to the escalating prevalence of morbidity worldwide including the Arab countries. Due to the serious consequences of the untreated sleep disordered breathing, this article will emphasize on the importance of early recognition, key clinical manifestations, and how to treat and prevent the disease.
  7 5,173 783
* Source: CrossRef
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