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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.
  39,915 1,721 7
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.
  13,560 976 1
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.
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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.
  3,749 5,937 5
Alteration in pulmonary perfusion due to iatrogenic pulmonary vein stenosis: A mimicker of pulmonary embolism
Wesam Ostwani, Mohammad Arabi
October-December 2011, 1(2):58-60
DOI:10.4103/2231-0770.90918  PMID:23210011
Iatrogenic pulmonary vein stenosis (PVS) is a known, yet rare, complication of atrial radiofrequency ablation. Alterations in pulmonary perfusion may mimic massive pulmonary embolism on a ventilation/perfusion (V/Q) scintigraphy. This is particularly important due to the overlap in presenting clinical symptoms. The present case illustrates the functional significance of PVS and the changes in perfusion in response to angioplasty.
  9,077 387 3
Nocturnal enuresis: A topic review and institution experience
John Michael DiBianco, Chad Morley, Osama Al-Omar
October-December 2014, 4(4):77-86
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.
  3,608 5,732 5
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
  7,591 1,036 18
Case reports and research productivity among Syrian medical students: Review, reality, and suggested solutions
Naji Alhamid, Nawar Almounayer, Bana Alsabbagh, Baseel Atassi
October-December 2015, 5(4):101-105
DOI:10.4103/2231-0770.165119  PMID:26629463
Medical students are precious seeds for better future medical research. Case reports writing may represent a relatively simple first step for beginners. Only 47 case reports are published in the literature by Syrian Medical Institutions compared to more than 500 case reports in a comparable country in the last 5 years. Many obstacles stand against developing fruitful research environment in Syria. Increasing awareness to research productivity in Syria along with comparative analysis is discussed in this article.
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Application of case discussions to improve anatomy learning in Syria
Mohammad Ayman Sabbagh
October-December 2013, 3(4):87-91
DOI:10.4103/2231-0770.120499  PMID:24327966
Aims: Designing a new approach for learning gross anatomy to improve students' motivation to study anatomy and to enable them to learn independently through case discussion. Materials and Methods: The study included newly registered students in the first academic year. The total number of students was 165, who were divided by alphabetical order into 15 groups of 11 students. Each group was led by one faculty member and each faculty member lead 3 groups. Each group met twice a week for 2 weeks to discuss one case related to the upper limb anatomy. Students took pre- and posttests and completed an opinion questionnaire about the case discussions. Results: The pretest score shows that 20% of the students received grades of 60% or above and that 80% received grades less than 60%. The posttest showed that 45% of the students received grades of 60% or above and that 55% received grades less than 60%. There was a significant difference between the pre- and posttest for grades <60% (P = 0.0000) and less significant for grades >60% (P = 0.0023). In addition, 17% of students achieved the same results (less than 60%) in both the pre- and posttests. The questionnaire revealed that all students stated that the discussion method was useful in their learning process, helped them to increase their motivation to study anatomy (85%), know the usefulness of studying anatomy (84%), and understand the problems (91%). Conclusions: The implementation of the case discussion in teaching anatomy can increase the students' understanding and motivate them to learn.
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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.
  6,241 759 11
Erlotinib eradicates brain metastases from epidermal growth factor receptor mutant non-small cell lung cancer
Siavash Jabbari, Michael Pins, Kimberly Kruczek, Chadi Nabhan
October-December 2011, 1(2):52-54
DOI:10.4103/2231-0770.90916  PMID:23210009
Erlotinib is active in patients with lung cancer; especially those who demonstrate a mutation in exons 18-21 in the epidermal growth factor receptor (EGFR) gene. Patients with lung cancer and brain metastases have poor prognosis as systemic chemotherapy is ineffective in treating the central nervous system (CNS) metastases due to its inability to cross the blood brain barrier. Herein, we report a case of a 61 year old female who presented with stage IV adenocarcinoma of the lung with bilateral cerebral and cerebellar CNS involvement. The patient's tumor harbored a mutation in exon 19 in the EGFR gene. Treatment with erlotinib was started as soon as the molecular studies were available with remarkable and complete radiographic response in the CNS disease, and complete resolution of the previously detected metastases. The patient did not receive any other CNS intervention and radiation was not given due to the lack of CNS symptoms.
  6,387 532 -
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
  5,707 1,003 3
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.
  5,549 341 5
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.
  4,984 788 29
The cardiac patient in Ramadan
Majed Chamsi-Pasha, Hassan Chamsi-Pasha
April-June 2016, 6(2):33-38
DOI:10.4103/2231-0770.179547  PMID:27144139
Ramadan is one of the five fundamental pillars of Islam. During this month, the majority of the 1.6 billion Muslims worldwide observe an absolute fast from dawn to sunset without any drink or food. Our review shows that the impact of fasting during Ramadan on patients with stable cardiac disease is minimal and does not lead to any increase in acute events. Most patients with the stable cardiac disease can fast safely. Most of the drug doses and their regimen are easily manageable during this month and may need not to be changed. Ramadan fasting is a healthy nonpharmacological means for improving cardiovascular risk factors. Most of the Muslims, who suffer from chronic diseases, insist on fasting Ramadan despite being exempted by religion. The Holy Quran specifically exempts the sick from fasting. This is particularly relevant if fasting worsens one's illness or delays recovery. Patients with unstable angina, recent myocardial infarction, uncontrolled hypertension, decompensated heart failure, recent cardiac intervention or cardiac surgery or any debilitating diseases should avoid fasting.
  5,076 407 2
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.
  4,962 503 3
Visceral adipose tissue influences on coronary artery calcification at young and middle-age groups using computed tomography angiography
Rami M Abazid, M Obadah Kattea, Sawsan Sayed, Hanaa Saqqah, Mohammed Qintar, Osama A Smettei
July-September 2015, 5(3):83-88
DOI:10.4103/2231-0770.160242  PMID:26229760
Purpose: The purpose of the study was to evaluate the impact of excessive visceral adipose tissue (VAT) on subclinical coronary atherosclerosis and coronary artery calcifications (CAC) in young and middle-age groups using multislice computed tomography. Methods: This study is a single center, cross-sectional study. Eligible patients (n = 159), who under the age of 61 years, with chest pain and mild to moderate probability to have coronary artery disease (CAD) were enrolled. Coronary calcium score and epicardial adipose tissue (EAT) were measured at the level of the left main coronary artery while VAT was measured at the level of the iliac crest. Results: The average age was (48 ± 8 years). The mean VAT was (38 ± 21 cm 2 ) with no significant difference between men and women (38 ± 22 vs. 37 ± 19 P = 0.8) respectively. Student's t-test analysis showed significantly higher VAT in patients with detectable CAC than patients with no CAC (48 ± 24 vs. 33 ± 18 P = 0.00002), respectively. Univariate regression analysis showed that VAT and EAT, are strong predictor for CAC (hazard ratio [HR] 1.034, 95% confidence interval [CI: 1.016-1.052]. P <0.001 and [HR] 1.344, 95% CI: [1.129-1.601] P = 0.001), respectively. Conclusion: Excessive VAT is significantly associated with positive CAC. VAT can strongly predict subclinical CAD in individuals at young and middle-age groups.
  5,043 157 2
Hypoglycemia due to an adult-onset nesidioblastosis, a diagnostic and management dilemma
Mohammed Qintar, Firas Sibai, Mohammad Taha
April-June 2012, 2(2):45-47
DOI:10.4103/2231-0770.99164  PMID:23210022
We describe a case of a 40 year old patient with recurrent severe fasting and postprandial symptomatic hypoglycemia that occurred 6 years after gastric bypass surgery. The hypoglycemia was associated with increased insulin and C peptide but all diagnostic modalities for localizing an insulinoma were negative. Medical management failed to control symptoms and the patient underwent subtotal pancreatectomy. Surgical tissue examination confirmed the diagnosis of noninsulinoma pancreatogenous hypoglycaemia syndrome (NIPHS) or nesidioblastosis. Initially after surgery the patient had full remission but after 6 months hypoglycemia recurred. However, this time it was well-controlled with octreotide treatment.
  4,573 613 4
Muslim patients in Ramadan: A review for primary care physicians
Heba Abolaban, Ahmad Al-Moujahed
July-September 2017, 7(3):81-87
DOI:10.4103/ajm.AJM_76_17  PMID:28791239
Fasting Ramadan, in which Muslims abstain from specific habits and behaviors from dawn to sunset, is one of the five Pillars of Islam. While there are several exemptions from fasting, many Muslim patients with acute or chronic medical conditions still choose to fast, which may adversely affect their health if not addressed properly. Some patients may not be well educated about the effects of some medical treatments and procedures on the validity of their fast, which can unnecessarily lead to suboptimal management of their conditions or treatment nonadherence. Since spirituality, religiosity, and personal beliefs affect patients' health behaviors and adherence to treatments, health-care providers need to learn how fasting Ramadan can affect the health of their Muslim patients, especially those with chronic medical conditions, and how to help them achieve safe fasting. This article aims to provide an overview of the main topics that primary care physicians may need to know in order to improve their cultural competence when caring for their fasting Muslim patients.
  4,947 153 -
The metrics of Syrian physicians' brain drain to the United States
Mohammad Arabi, Abdul Ghani Sankri-Tarbichi
January-March 2012, 2(1):1-2
DOI:10.4103/2231-0770.94802  PMID:23210012
  4,555 458 2
Membranous nephropathy: Treatment outline and risk stratification
Ziad Arabi
July-September 2012, 2(3):60-64
DOI:10.4103/2231-0770.102278  PMID:23826548
Membranous nephropathy (MN) is the most common cause of nephrotic syndrome in adult. However, the exact etiology and the best treatment approach are still unclear. It is imperative to understand the nature of and prognosis of MN before initiating treatment which may include disease specific therapy based on a careful risk-stratification approach.
  4,327 662 -
Childhood obesity-an insight into preventive strategies
Subhranshu Sekhar Kar, Rajani Dube, Sitanshu Sekhar Kar
October-December 2014, 4(4):88-93
DOI:10.4103/2231-0770.140653  PMID:25298951
Childhood obesity is now a global problem throughout the world. The major factors affecting weight regulation and the development of obesity in children are the result of a large number of biological, behavioral, social, environmental, and economic factors and the complex interactions between them that promote a positive energy balance. The changes in the dietary habits with the adoption of sedentary life style increases manifold obesity-related diseases and their complications. An obese child later on grows up to become an obese adult. Therefore, the role of primary prevention along with methodical diet control, behavioral changes, and physical activity are the important strategies against the battle of childhood obesity.
  4,084 626 3
Assessment of noise levels in 200 Mosques in Riyadh, Saudi Arabia
SA Al Shimemeri, Chirag B Patel, Al Fayez Abdulrahman
October-December 2011, 1(2):35-38
DOI:10.4103/2231-0770.90914  PMID:23210007
Introduction : Noise-induced hearing loss (NIHL) is a recognized concern within the context of occupational and general health. However, noise levels are seldom studied at nonworkplace and nonabode sites that are visited regularly, e.g., places of worship. The purpose of this study was to assess the noise levels inside and outside of mosque prayer rooms and to compare the levels with established noise tolerance limits. Materials and Methods : A portable digital sound level meter was used to determine the noise level (measured in dB) inside and outside of mosque prayer rooms. The highest (peak) and lowest noise levels from each recording were tabulated. Statistical analysis was performed using a two-tailed Student's t-test(alpha = 0.05). Results : Noise levels were measured at 200 mosque prayer rooms from all 15 municipal districts of Riyadh, Saudi Arabia. Of these, 151 prayer rooms (75.5%) had both inside and outside noise measurements and the remaining 49 prayer rooms (24.5%) had only inside noise measurements. There was significantly greater noise outside compared to inside the prayer rooms, for both the highest noise level (outside: 87.8 ± 4.8 dB compared to inside: 85.8 ± 5.4 dB, P < 0.0001) and lowest noise level (outside: 58.4 ± 3.8 dB compared to inside: 56.6 ± 3.6 dB, P < 0.00001). In all, 112 of the inside highest level measurements (56%) and 113 of the outside highest level measurements (74.8%) were greater than 85 dB, the sound level at which NIHL has been shown to occur in occupational settings. Conclusion : A large proportion (56%) of mosque prayer rooms with inside peak noise measurements were above acceptable levels (85 dB), however, prayers certainly do not last for 8 continuous hours. Therefore, the level of noise at mosques is acceptable and in compliance with international norms of hearing safety; moreover, it does not present any risk to hearing in the long run.
  4,209 485 1
Scintigraphic assessment of patellar vascularity in total knee replacement surgeries following lateral release
Padma Subramanyam, P Shanmuga Sundaram, Narasimha Rao
July-September 2012, 2(3):54-59
DOI:10.4103/2231-0770.102277  PMID:23826547
For a total knee replacement (TKR) to function well, the patella must track centrally in the trochlear groove. Lateral retinacular release (LR) is performed as an integral step in TKR to avoid maltracking. Patellar resurfacing and infra patellar fat pad excision are other small surgical procedures performed during TKR that can also easily deprive the patella of its vascularity. A three phase bone scan helps in the assessment of patellar vascularity. Literature review reveals a variable association (10-56%) of LR and patellar hypovascularity in Caucasians. Objective: LR release done in TKR is known to compromise patellar viability, while its extent and severity is still debated. Our prospective study was undertaken to evaluate the effects of LR on patella along with other variables like patellar resurfacement, fat pad excision, patelloplasty on knees by 99m Technetium labeled methylene diphosphonate ( 99m Tc MDP) three phase bone scintigraphy (TBS). Materials and Methods: 45 TKRs were done between Jan 05 and Jan 06. Of them, 15 patients (21 knees) of primary TKR were considered prospectively. Patients undergoing uni/bilateral TKR due to symptomatic knee osteoarthritis were only selected for this study. Pre- and immediate postoperative TBS was done with modified positioning of knee joints (adducted, externally rotated and flexed to 30°) to visualize patellae away from knee joint, which otherwise gets superimposed on the femoral condyles. A follow-up TBS at 8-10 weeks was done in patients showing immediate post-op patellar hypovascularity. Results: 12/21 knees (57%) needed LR. Of these 12 knees, 8 (66%) showed hypovascularity; whereas 9 knees with no LR, 1 knee showed hypovascularity. All 9 knees (8 post LR+1 without LR) with hypovascularity underwent TBS again at 8-10 weeks and were found to show improvement in their vascularity status in all cases. Conclusion: Our study showed a higher incidence of LR in our population (57%). Association of LR and patellar ischemia was significant, about 16 times the risk. MDP bone scintigraphy is the only objective tool to quantify patellar vascularity. Overall 42.8% knees post-TKR had a transient patellar ischemia, and 38% of them were following LR. All of them recovered at 8-10 weeks postoperatively.
  3,977 424 2
Antibiotic utilization pattern in a general medical ward of a tertiary medical center in Saudi Arabia
A Al Shimemeri, H Al Ghadeer, Z Memish
July-September 2011, 1(1):8-11
DOI:10.4103/2231-0770.83717  PMID:23210003
To assess the pattern of antibiotic utilization and outcome of patients with bacteremia in a General Medical Ward, all positive blood cultures (BC) over a 12-month period from January 1994 to December 1995 were retrospectively reviewed. Fifty-two positive BC were recorded in 43 patients (63% males, 37% females; mean age 65.9 ± 16.6). 72% of the patients received antibiotics before or soon after obtaining the BC, and ceftriaxone was the most frequently-prescribed antibiotic (41.93%), either alone or in combination with other antibiotics. The bacteremia was due to gram-positive cocci in 60.46% of cases, gram-negative rods in 30.23%, and gram-positive rods in 9.30%. Positive BC due to contamination were not included. The most common gram-positive cocci were Staphylococcus epidermidis, followed by S. aureus, while the most common gram-negative bacilli were Brucella species, Proteus mirabilis, and Klebsiella sp. The suspected sources of the bacteremia were respiratory (21.2%), urinary (19.2%), or skin (19.2%). A subsequent change in the antibiotics regimen was done in 69.76% cases after BC results became available with no apparent effect on the outcome. Adding vancomycin and clindamycin was the most frequent change done (19.4% for each equally). Complications developed in 69.76% of patients, with 88.66% of them suffering from sepsis/shock. 69.23% of the patients improved and 30.77% expired; death was related to infection in 87.5% of cases. In conclusion, most bacteremia in the medical ward of the hospital were due to gram-positive cocci, which should be considered in antibiotic selection prior to BC. Risk factors for acquiring Brucellosis should always be obtained.
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