standard

Background: Breast cancer (BC) is one of the most prevalent malignancies. BC survivors have higher risk of second primary cancers than the general population. There is an increased interest in BC survivor management, including the prevention of these second cancers. The aim of this study was to assess the risk of gynaecological malignancy (GM) as second neoplasm among BC patients in our population. Methods: Patients with invasive BC diagnosed from 1980 to 2014 included in the Girona Cancer Registry were included. The incidence of second GM in these patients was compared to those in the general population. Second primary cancer was stated as a tumour diagnosed after 2 months from the BC diagnosis. Standardized incidence ratios (SIR) and absolute excess of risk (AER) were calculated. Results: 9,717 patients were diagnosed with invasive BC during this period, with a median age at diagnosis of 61 years, and a median follow-up of 7.9 years. 117 of them developed a second GM. By tumour type, the only statistically significant higher SIR was observed for corpus uteri cancer (SIR:2.28 95% CI 1.82-2.83; AER:6.43 95% CI 4.13-9.14). After reviewing the histology of the corpus uteri cancer cases, we found that 71.4% were type I (endometrioid adenocarcinoma), 15.5% type II (serous adenocarcinomas and clear cell carcinomas), 10.7% carcinosarcomas, 2.4% sarcomas and there were no unspecified malignant neoplasms. Conclusion: BC survivors have an increased risk of corpus uteri cancer, with an increase in unfavourable histologies compared to the general population. Lifelong primary and secondary prevention interventions should be recommended for these patients.

Background: The aim of the study was to evaluate radiographic features of systemic sclerosis-associated interstitial lung disease. Patients and methods: 116 patients with systemic sclerosis-associated interstitial lung disease (SSc-ILD) from 2010 to 2019 comprised our retrospective study. All patients were subject to high resolution computed tomography (HRCT). ILD patterns were classified into 7 patterns as IIPs and analyzed with pathology. We chose two staging method and two semi-quantitative score methods to evaluate the HRCT performance and analyzed with pulmonary function tests. Results: Ground-glass opacities were the most common presentation on HRCT, followed by interlobular septal thickening, reticular opacities, intralobular interstitial thickening; honeycombing, traction bronchiectasis and nodules can also be observed. The most common pattern of SSc-ILD was nonspecific interstitial pneumonia (NSIP), secondly was UIP. There was no difference in ILD pattern between HRCT and pathology, and revealed a high congruence. The four HRCT evaluating methods presented in this study all had significant relationships with PETs. Conclusion: The most common pattern of SSc-ILD was nonspecific interstitial pneumonia (NSIP). The ILD patterns of HRCT coincide very well with histology, and will replace pathology as the gold standard for diagnosis and evaluation of SSc-ILD.

Context: Perioperative management of morbidly obese patients undergoing bariatric surgery is challenging. Lacking standardized perioperative protocols, complication rates may be high. This retrospective study aims to quantify the incidence of significant blood pressure decreases on induction of anesthesia and intraoperative hypoxemia, before implementation of a standardized protocol designed for bariatric surgery. Design: Retrospective, observational study. Setting: A 250-bed county hospital in northern Sweden. Subjects: 219 morbidly obese patients (body mass index > 35 kg/m2) who underwent bariatric surgery between 2003 and 2008. Main outcome measures: Incidence of systolic blood pressure (SAP) falls to less than 70% of the preoperative baseline during induction of anesthesia and incidence of perioperative hypoxemia. Results: The incidence of confirmed SAP falls to below 70% of baseline at induction of anesthesia was 56.2% (n = 123/219). This incidence rose with increasing age (p < 0.001) but not with body mass index (BMI). 3.7% (n = 8/219) of cases were marked as difficult intubations. A transient period of hypoxemia was observed in 6.8% (n = 15/219) and was more common with increasing BMI (p = 0.005). Fourteen different drug combinations were used in the study population. Of those administered an induction anesthetic drug, 72.6% (n = 159/193) were given an overdose when calculated by lean body weight, but this did not correlate significantly to SAP falls (p = 0.468). Conclusion: The incidence of a significant blood pressure fall upon induction of anesthesia was common. The incidence of airway and ventilation problems were low. Overdosing of anesthetics and excessive variation in applied anesthesia methods were found.

Background: Dysmenorrhea is menstrual disorder that affects about 40% - 90% of women worldwide, it is associated with oxidative stress. The current treatment of this condition is administration of non-steroidal anti-inflammatory drugs, which when frequently used, may affect organs. Objective: Assess the hepatotoxicity and nephrotoxicity side effects related to dysmenorrhea and its treatment Materials and methods: A survey (questionnaire) was designed and implemented on 689 female students of the University of Dschang. After this, and following the inclusion criteria, 191 blood samples were collected for assay of hepatotoxicity markers (transaminases, albumin), nephrotoxicity indicators (creatinine, urea, total protein) and the inflammation associated indicators. The measurements were performed on fully automated Olympus AU 400 Analyzer, using standard reagent kits. Results: Subjects with untreated dymenorrhea lasting more than five years had a significantly high level (p < 0.05) of ALT (39.47 ± 15.74 IU/L) and AST (44.37 ± 13.74 IU/L). Transaminases levels were significantly associate (p < 0.01) and positively correlate (0.251 for ALT and 0. 223 for AST) with the disease duration. Dysmenorrheic individuals on medication for more than 9 years had significantly higher ALT (25.14 ± 7.85 IU/L) and AST (35.26 ± 0.70 IU/L) levels (p < 0.05) compared to those under treatment for less than 5 years (19.37 ± 8.27 UI/L and 27.68 ± 8.56 UI/L). The use of analgesics, regardless of the duration of treatment, had normal creatinine clearance (107.44 ± 30.86 ml/min), compared to those treated with either anti-inflammatory drugs (71.56 ± 26.44 ml/min), or a combination of analgesics and anti-inflammatory drugs (81.34 ± 31.97 ml/min), which was significantly reduced (p < 0.05). Conclusion: Dysmenorrhea duration, type and duration of treatment potentially expose participants to liver and kidney disorders.

Objective: To describe some aspects of the quality of ambulance care and completeness of information in the transfer forms of emergency patients who arrived in ambulances to the National Hospital of Sri Lanka (NHSL). Methods:This was a descriptive study. All ambulances arrived at the NHSL during the study period with an emergency patient were selected (n=409) and from those 250 transfer forms, which could be traced were taken. An interviewer-administered questionnaire was used for ambulance staff. A Checklist, which has been derived from the standard patent chart, was used to determine the availability of information on transfer forms. Results: Of the 409 ambulances, the patient was accompanied by a doctor in 4% (n=16), a nurse in 4% (n=15) and Emergency Medical Technicians (EMTs) in 1% (n= 4), and there were 675 miner employees and 409 drivers. Twenty six percent (n= 4) of doctors, 12.5% (n= 2) of nurses, 100% (n=4) of EMTs, 56.9% (n=189) of drivers and 24.3% (n=164) of minor employees had received training in emergency medicine/pre-hospital care. The time interval between receipt of the message and loading the patient to the ambulance was >15 minutes on 19% (n= 75) of the occasions and from the latter time to commencement of the journey was >15 minutes on 7% (n=27) of the occasions. The call number of sending facility 0.4% (n=1) and sending time 33.2% (n=83) were poorly documented. The past surgical histories 20.8% (n=52), chronic diseases 48% (n=120), psychological problems 13.2% (n=33) and allergies 9.2% (n=23) were poorly documented. Details of physical examination findings except cardio-vascular system were not documented in >50% of transfer forms. Medications had been documented fairly (>60%) in most of the transfer forms and however, the procedures (IV fluids, ECG) were poorly documented (<30%). Conclusion: The completeness of information in the transfer form was not up to standards. This emphasizes for need of well-structured standard transfer form in the country.

Introduction: Candidiasis is more frequent in human immunodeficiency virus (HIV)-infected patients and knowledge about the distribution and antifungal susceptibility of oral Candida species is important for effective management of candidiasis. Material and Methods: An oral rinses sample collected from hundred HIV-infected patients with and without clinical evidence of oral candidiasis in this study at the Infectious Department/Tripoli Medical Center, Libya. Species identified by standard phenotypic and conventional methods and in vitro susceptibility testing of the yeast isolates to antifungals were performed using the Disc diffusion method protocol as recommended by the Clinical Laboratory Scientific Institute. Results: Oral Candida colonization is detected in all patients with and without clinical syndromes, and Candida albicans were accounted for (74%), C. dubliniensis (11%) and C. glabrata (6%). A high proportion of Candida species (42%) showed decreased susceptibility to fluconazole. Among C., albicans more than 30% of isolate were resistant to most new azole antifungal including fluconazole, itraconazole, posoconazole and voriconazole. Conclusions: A significant number of oral Candida species particular Candida albicans exhibiting decreased susceptibility to fluconazole were isolated from colonized HIV-infected individual, given the high incidence and severity of fungal infections in HIV-infected individuals. The results of this study reinforce the importance of antifungal susceptibility testing, which contributes to the therapeutic strategies and highlights the need for continuous surveillance of Candida colonization in this population.

Nonsurgical fertility control is increasingly advocated as more cost-effective than surgical sterilization to manage stray animal populations in a different part of the world. An experimental study was conducted from December 2018 to April 2019 at Mekelle University to evaluate the effect of single bilateral intratesticular injection of cetrimide 2% in adult albino mice. A total of 20 clinically healthy albino mice selected based on their age and sex and were divided randomly into five groups and evaluation was conducted for 30 days after intratesticular injection of cetrimide solution 2% at the dose rate of 5, 10, 15 and 20 mg per testis and for control 0.1 mL normal saline per testis per 100 g body weight were given. All albino mice were evaluated for 30 days at a fixed interval. Change in body weight, scrotal width, sexual behavior, and fertility performance was also assessed. On day 30, all albino mice were sacrificed for histopathological study. Means  ±  Standard deviation of the mean, one-way, and a mixed model ANOVA (for repeated measures) was used to summarize the data, determine the effects of group and time on bodyweight and scrotal width. The significant increase in body weight (p - 0.001) and significant reduction of scrotal width (p - 0.001) were noted in all cetrimide treated in comparison to control groups. In addition, there was a significant (p < 0.05) reduction of scrotal width in albino mice after intratesticular injection of cetrimide on day 1, 10, 15, 20, 25, and 30 with respect to their experimental groups. Testicular histology revealed that there were multinucleated giant cells in seminiferous tubules, derangement of tubular architecture along with infiltration of leucocytes and appearance of fibrous tissue were seen on testicular sections at a dose rate of 15 and 20 mg. Similarly, a significant change in the sexual behavior of the treated males and no pregnancy was detected on female albino mice after 21 days post-coital at 10, 15, or 20 mg cetrimide-treated males. In conclusion, a single bilateral intratesticular injection of cetrimide 2% at a dose of 15 and 20 mg might provide an effective way of sterilization and may be considered as an alternative to surgical castration in male animals. Besides, further assessment should be done in the future to identify the mechanism of infertility.

Frequency specific microcurrent (FSM) has been used to treat myofascial pain syndrome [1,2] fibromyalgia associated with spine trauma [3], delayed onset muscle soreness [4], acute and chronic neuropathic pain [5] and chronic scarring in burn patients [6]. In this case, its use was modified to include not only the treatment of neuropathic pain but the treatment of neural adhesions in a patient with a ten year history of pain at rest and painful restricted range of motion following an ulnar nerve anterior transposition surgery in 2001. Eleven standard physical therapy sessions including augmented soft tissue mobilization using plastic tools, and muscle strengthening exercises and stretching failed to resolve symptoms. Three sessions of frequency specific microcurrent produced complete resolution of pain and symptoms. Patient remained symptoms free at one-year follow up.

Background: Primary lymphedema occurs as a result of genetic abnormalities of the lymph system. Currently, complex decongestive therapy is accepted as the standard treatment of the lymphedema. In this case presentation, we described the management of bilateral primary lower extremity lymphedema and the use of complex decongestive therapy. Case Report: A 62 years old female patient had stage III primary lymphedema on her left lower extremity and stage II primary lymphedema on her right lower extremity. The patient, who had morbid obesity, also had untreatable sleep apnea, urinary incontinence, umbilical hernia and hypertension controlled by drugs. She had stage 4 gonarthrosis according to Kellgren – Lawrence classification in her both knees. The patient received complex decongestive therapy as an outpatient. After 27 sessions of complex decongestive therapy, edema reduced in both lower extremities. Before the treatment started, the patient couldn’t go up and down stairs, get out and had difficulty mobility in the home. But after the treatment, the patient could go up and down 16 stairs by holding the railing, get out by two walking sticks and had less difficulty mobility in the home. However, due to gonarthrosis in her knees, her pain did not diminish. Conclusion: Complex decongestive therapy is effective in the management of bilateral primary lower extremity lymphedema, which progressed with multiple health conditions.

Aim and objectives: Endometrial Window of Implantation (WOI) is open in the midsecretory phase wherein the markers of invasion and cell adhesion are manifested .The primary objective was to find out the predictive value of Endometrial thickness and profile as a prognostic factors for embryo transfers during ART. Materials and Methods: Endometrial thickness assessment was performed with grey scale ultrasound on the day of transfer just before thawing the embryos in patients undergoing Frozen embryo transfer cycle after endometrial preparation. Results: The mean age and standard deviation of study population was is 33.26+5.95.Out of 69 patients there was clinical pregnancy in 33 patients , miscarriage in 10 patients and ongoing pregnacy in 23 patients. So the implantation rate was 47.83% (33/69), early miscarriage rate (pregnancy ending before 12 weeks) was 14.49%(10/69) and the ongoing pregnancy rate was 33.33% (23/69). Endometrial thickness < 6 mm had comparable implantation rates but low ongoing pregnancy rates. Conclusion: The ultrasound morphological and vascular grading of endometrial thickness and vascularity is useful to synchronise Day 5 embryo transfer and window and implantation thereby minimizing the loss of good embryos in nonreceptive endometrium.

Objectives: Tension-free vaginal tapes are the gold standard of the surgical treatment of stress urinary incontinence (SUI); however, long-term recurrence of SUI after this surgery has been a matter of problem. Here, we attempted to determine the incidence of its recurrence and to identify the risk factors of 4-year-recurrence of SUI after this surgery. Methods: Of all patients undergoing this surgery (n = 341, 2015-2019), 71 patients were met the study inclusion criteria. Of 71, SUI recurred in 8 patients, with the recurrence rate being 11.3%. The following three were identified to be independent risk factors: older age, history of delivery of macrosomic baby (>4 kg), and the presence of mixed urinary incontinence. The frequency of recurrence in cases with mixed incontinence amounted for 19.5%. Recurrence was 22 and 50% for women with macrosomic delivery once and more than twice, respectively. Conclusion: Advanced age, macrosomic delivery and mixed urinary incontinence have shown to be independent risk factors of recurrence of SUI after tension-free vaginal tape-obturator at 4 years. Key message: Stress urinary incontinence can recur so investigate possible risk factors is a priority. Our paper relates recurrence with: advanced age, fetal macrosomia and mixed incontinence.

TEmphysematous pyelonephritis (EPN) is a rare but potentially life-threatening necrotizing renal parenchymal infection characterised by the production of intra-parenchymal gas. The approach and the management of emphysematous has changed dramatically over the last two decades with the advent of computed tomography (CT)-based diagnosis and advances in antibiotic therapy as well as multidisciplinary intensive care of sepsis leading to an overall decline in mortality rates to 20-25%. The previously standard treatment for EPN which included nephrectomy of the affected kidney has been replaced by minimally invasive and nephron sparing surgery with better patient outcomes. We present our case series of 12 patients with EPN over a short period of two years treated at our tertiary care centre in South Western India.

Aims: To audit the use of cervical dilators, local anaesthetic, and failure rates in outpatient hysteroscopy over a two-year period in University Hospital Kerry. To review the experiences of women attending the outpatient hysteroscopy clinic (OHC) over a two-year period in University Hospital Kerry. Methods: Retrospective data review was carried out. Green-top Guideline No. 59: Best Practice in Outpatient Hysteroscopy, published by the Royal College of Obstetricians and Gynaecologists (RCOG), was the standard used for comparison. Results: Two hundred and twenty women were seen over a two-year period. The average age was forty-eight. The most common complaint being of menorrhagia/irregular bleeding per vaginum (PV). Local anaesthetic was used in just under one third of cases of which half required cervical dilatation. Most women reported experiencing mild to moderate levels of discomfort however most would opt for an outpatient hysteroscopic procedure again if required. Discussion/Conclusion: Outpatient hysteroscopy is a well-tolerated and safe procedure. Suitability for outpatient hysteroscopy is not predictable based on parity of menopausal status. Women would elect to undergo outpatient hysteroscopy again if required and this is likely due to several reasons including convenience and lack of requirement for general anaesthetic.

Background: Low back pain has recently been reported as the leading cause for disability worldwide. The diagnostic value of imaging has been estimated low. Led by own positive experience, however, we hypothesized that MRI can detect signs of facet joint pain. Methods: 15 patients and 15 controls were retrospectively assessed by two readers. They compared de-identified T2 weighted lumbar spine MRI scans. Facet joint size, shape, angle, joint space signal and degeneration were rated. Pain aetiology was proven with the diagnostic gold standard of medial branch blocks. Results: Facet joint angles and joint diameters were significantly larger in symptomatic patients, who also showed significantly higher grades of degeneration but no difference in joint space distances or shape or signal intensity. The readers were able to correctly identify symptomatic patients with good interrater reliability (kappa 0.5, sensitivity and specificity 0.87-0.93), positive (LR+= 6.7-7.2) and negative likelihood ratios (LR-=0.15). Conclusion: Contrary to recent publications, we could demonstrate differences between asymptomatic and symptomatic subjects showing the latter to have larger joints and more signs of degeneration. One can conclude from the strong LR+ and LR- values that MRI is a useful investigation to rule in or rule out facet pain.

This article reflects the opinion on a few of my clinical experiences involving symptoms and signs which are not mentioned in standard textbooks on medicine or clinical methods. These are clinical and a few radiological signs which I think worth discussing by clinical community, includes Muslim prayer’s feet, hyponatraemic bullae, early signs of oedema, PCV sign, hemi-semi-Hoffman’s sign and a few more.

Background: Even with current standard treatment after variceal bleeding which includes combination of nonselective b-blockers and repeated endoscopic variceal ligation, the risk of rebleeding and mortality are high. Statins exhibit an antifibrotic effect and improves HVPG. We evaluated whether addition of simvastatin to carvedilol plus EVL therapy reduces variceal rebleeds or death in patients with cirrhosis. Method: Patients with a variceal bleed 5 to 10 days before were randomly assigned to groups A [carvedilol (n = 69)] or group B [carvedilol (maximum dose - 12.5mg), and simvastatin (40mg/day) (n = 65)]. Primary end points were variceal rebleeding or death. Secondary end points were new complications of portal hypertension and serious adverse effects of drugs. Results: During a mean follow-up of 49.05 ± 25.74 weeks, composite end point i.e. rebleeding or death developed in 23 patients (33.3%) in group A and 12 patients (18.5%) in group B [HR for simvastatin = 0.512; 95% CI: 0.254 – 1.030; p = 0.06]. In subgroup analysis by excluding patients of Child C class, 18 patients (34.6%) in group A and 7 patients (13.6%) in group B developed composite end point [HR for simvastatin = 0.369; 95% CI: 0.154 – 0.887; p = 0.026]. 17.4% and 15.4% patients in group A and B developed additional secondary complication [HR = 0.86; 95% CI: 0.345-2.161; p = 0.75). No simvastatin induced significant adverse effects were found. Conclusion: Addition of simvastatin to carvedilol and EVL may reduce the rebleeding and death in patients with less advance liver disease.

Objective: To determine the diagnostic accuracy of Magnetic Resonance Imaging (MRI) to differentiate Benign and Malignant Parotid Gland Tumors taking histopathology as gold standard. Design: Cross sectional study. Place and duration of study: Department of Diagnostic Radiology, Lahore General Hospital, Lahore from January till July 2014. Methodology: 200 patients of age between 5 to 80 years of either gender with parotid gland swelling, having radiological evidence and clinical suspicion of parotid tumour like fixation to underlying skin, pain, facial palsy and cervical lymphadenopathy were taken. T1 and T2 plain and contrast enhanced 1.5 Tesla MRI unit using standard imaging coil was then carried out. Imaging was further evaluated for the presence or absence of benign or malignant parotid gland tumours using histopathology as a Gold standard. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of MRI were taken against the gold standard. Results: There were 170 males and 30 females having mean age of 40.27±15.04 and 40.12±12.15 years respectively. Sensitivity, specificity, positive predictive value and negative predictive value of MRI were 90.4%, 89.33%, 93.39% and 84.41% respectively. The diagnostic accuracy of MRI to differentiate benign and malignant parotid gland tumours was 90%. These results were taken against surgery histopathology as a gold standard. Conclusion: MRI is highly accurate in differentiating malignant & benign tumours of parotid glands and can be used as an adjunct to histopathology for pre-operative evaluation of the parotid gland tumours.

Meigs’ syndrome is a rare condition characterized by the presence of a benign fibroma of the ovary, ascites and pleural effusion. Other benign cysts of the ovary (such as struma ovarii, mucinous cystadenoma, serous cystadenoma and teratomas), leiomyoma of the uterus, and secondary metastatic tumours to ovary if associated with hydro thorax and ascites are referred to as ‘Pseudo-Meigs” syndrome. It very uncommon and diagnosis is made difficult by symptoms that usually mimic disseminated malignancy or tuberculosis. The gold standard treatment is laparotomy and, by definition of the syndrome, after tumor removal, the symptoms resolves and the patients become asymptomatic. We presented an 18 years old girl with giant ovarian serous cystadenoma with associated pseudo-meigs syndrome, successfully managed in a low resources setting.

Five experimental feeding trials were conducted to investigate the performance of Heterobranchus Bidorsalis fingerlings to graded levels (0%, 25%, 50%, 75% and 100%) of Sphenostylis Stenocarpa seed meal diets. Complete randomized design with triplicate groups of fingerlings was used for the study for ten weeks. The proximate, anti-nutritional factor and amino acid profile of the S. stenocarpa was analysed. The study showed that treatment C with 50% inclusion of Sphenostylis Stenocarpa meal was significantly different (p < 0.05) and performed best among other treatments in terms of the net weight gain, standard growth rate, and survival. The feed conversion ratio was best in treatment C but not significantly different (p > 0.05) to other treatments.

A series of Schiff bases of diphenylamine derivatives have been synthesized and evaluated in vitro for their antibacterial activity against pathogenic both Gram-positive bacteria B. subtilis and Gram-negative bacteria E. coli using ciprofloxacin as standard drug at conc. of 50 µg/ml and 100 µg/ml. The structures of these compounds were established on the basis of IR and 1H-NMR spectral analysis. The compound (3d) displayed potent antibacterial activity against Bacillus subtilis (17 and 15mm) and Escherichia coli (19 and 17mm) by disc diffusion method.